THE  LIBRARY 


THE  UNIVERSITY 


OF  CALIFORNIA 


LOS  ANGELES 


GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


LOCAL  AND   REGIONAL 
-    ANESTHESIA 


With  Chapters  on  Spinal,  Epidural,  Paravertebral,  and  Para- 
sacral  Analgesia,   and  on  other  Applications  of  Local  and 
Regional  Anesthesia  to  the  Surgery  of  the  Eye,  Ear,  Nose  and 
Throat,  and  to  Dental  Practice 


BY. 

CARROLL  W.  ALLEN,  M.  D. 

ASSISTANT  PROFESSOR  OF  CLINICAt  SURGERY  AT  THE  TULANE  UNIVERSITY  OF  LOUISIANA, 
NEW  ORLEANS;  LECTURER  AND  INSTRUCTOR  IN  GENITO-URINARY  AND  RECTAL  DISEASES 
AT  THE  NEW  ORLEANS  POLYCLINIC;  VISITING  SURGEON  TO  THE  CHARITY  HOSPITAL 


WITH  AN  INTRODUCTION  BY 

RUDOLPH    MATAS,    M.  D. 

PROFESSOR  Or  GENERAL  AND  CLINICAL   SURGERY  AT  THE  TULANE  UNIVERSITY  OF 
LOUISIANA,  NEW  ORLEANS,  ETC. 


SECOND  EDITION,  RESET 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS   COMPANY 

1918 


Copyright,  igi4,  by  W.  B.  Saunders  Company.     Reprinted  April,  1915,  and  November,  1916. 
Revised,  entirely  reset,  reprinted,  and  recopyrighted  March,  1918 


Copyright,  1918,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

W.    B.    SAUNDERS    COMPANV 
PHILADELPHIA 


Libra." 


TO 

RUDOLPH  MAT  AS 

SURGEON,  SCHOLAR,  TEACHER,  FRIEND 

ONE   OF  THE    PIONEERS    IN    THE    FIELD  OF  LOCAL  AND  REGIONAL 
ANESTHESIA,  UNDER   WHOSE    GUIDANCE  THE  AUTHOR   WAS  IN- 
ITIATED   INTO    SURGERY,   WHOSE    EXAMPLE    AND  FRIEND- 
SHIP   PROMPTED    THE     CONCEPTION    OF     THIS    WORK, 
AND  WHOSE  TEACHINGS  AND  WRITINGS  HAVE  CON- 
TRIBUTED MANY  PAGES    OF  THE  TEXT,  THIS 
VOLUME    IS    GRATEFULLY    DEDICATED. 


53S2G5 


INTRODUCTION 


FOR  nearly  twenty  years  the  control  of  pain  in  surgical  opera- 
tions by  local  and  regional  methods  has  been  the  subject  of  our  earnest 
study.  As  director  of  the  surgical  clinics  of  the  College  of  Medicine 
of  the  Tulane  University  since  1895,  we  began  to  utilize  the  large 
clinical  material  at  our  command  in  the  effort  to  diminish  the  indica- 
tions for  general  narcosis,  and  to  substitute  for  the  immediate  dangers 
of  chloroform,  which  was  then  the  routine  anesthetic  in  almost  all 
Southern  clinics,  the  more  laborious  but  far  safer  methods  of  periph- 
eral analgesia.  Beginning  with  a  purely  local  and  peripheral  technic, 
in  which  intradermal  infiltration  and  massive  edematization  with 
dilute  isotonic  cocain  solutions  were  chiefly  utilized,  in  accordance 
with  the  principles  laid  down  by  Corning,  Halsted,  Reclus,  and 
Schleich,  we  soon  advanced  from  the  minor  work  of  the  dispensary 
to  the  more  ambitious  fields  of  major  surgery. 

In  1897  we  discarded  cocain  and  adopted  beta-eucain  and  soon 
became  engrossed  in  the  neuroregional  methods1  alone  or  combined 
with  massive  infiltration,  which  rapidly  expanded  in  every  direction, 
yielding  the  most  gratifying  and,  at  that  time,  almost  incredible 
results.  The  pursuit  of  this  regional  method  was  carried  out  with 
so  much  vigor  and  enthusiasm  that  in  I9OO2  we  were  able  to  publish 
two  extensive  reports  which  reviewed  the  progress  of  our  work  and 

1  In  referring  to  regional  methods  we  exclude  the  spinal  or  subarachnoid  method 
(L.  Corning,  1886-1894);  Bier  (1899)  as  a  central  method. 

After  an  experience  with  over  300  applications  of  this  method  with  cocain  and  its 
various  substitutes,  we  experienced  a  transition  from  a  state  of  great  enthusiasm  to  one 
of  decided  depression,  having  learned  by  hard  experience  and  careful  study  of  our  results 
that  the  benefits  of  this  procedure  were  more  apparent  than  real.  Since  then  we  have 
restricted  the  application  of  spinal  analgesia  to  a  very  circumscribed  and  steadily  smaller 
group  of  indications.  , 

2  "The  Growing  Importance  and  Value  of  Local  and  Regional  Anesthesia  in  Minor 
and  Major  Surgery,"  Transaction  of  Louisiana  State  Med.  Assoc.,  April,  1900,  pp.  1-78; 
"Local  and  Regional  Anesthesia  with  Cocain  and  Other  Analgesic  Drugs,"  Philadelphia 
Med.  Jour.,  November  3,  1900.  pp.  1-72. 

1 


2  INTRODUCTION 

that  of  others  and  gave  an  account  of  the  considerable  success  that 
we  had  obtained  in  the  invasion  of  new  territories. 

By  blocking  the  nerve-trunks  at  their  exit  from  the  cranial  foramina, 
jaws  were  resected,  the  tongue  and  floor  of  the  mouth  excised,  and,  by 
a  similar  process,  craniotomy,  thyroid  and  laryngeal  resections,  ampu- 
tations of  the  extremities,  resection  of  joints,  thoracotomies,  hernias, 
and  the  entire  domain  of  genito-urinary,  rectal,  and  a  considerable 
share  of  pelvic  and  abdominal  surgery  became  subservient  to  the 
new  methods.  In  this  way  we  were  able  to  show  in  1900  that  fully 
50  to  60  per  cent,  of  the  operations,  which  six  years  before  would 
have  required  a  general  narcosis,  had  become  amenable  to  local  and 
regional  anesthesia. 

Fourteen  years  have  elapsed  since  that  time.  Great  transforma- 
tions have  taken  place  in  our  methods  of  general  narcosis.  Chloro- 
form, which  for  half  a  century  had  reigned  supreme  as  the  autocrat 
of  the  operating  theater,  has  been  practically  banished  from  the 
clinics  of  the  South — its  last  stronghold.  Ether  by  the  open  mask 
and  drop  method  has  entirely  supplanted  it;  and  now  nitrous-oxid 
gas  in  combination  with  ether,  alone  or  with  oxygen,  is  gaining  favor 
steadily  in  our  main  operative  and  especially  private  clinics.  The 
effect  of  this  revolution  in  reducing  the  immediate  mortality  of 
general  narcosis,  and,  to  some  extent,  in  diminishing  the  postanes- 
thetic  risks,  is  universally  recognized.  However,  the  problem  of 
shock,  the  secondary  nausea  and  vomiting,  the  pulmonary  com- 
plications, embolism  and  thrombosis,  and,  above  all,  the  degen- 
erative auto-intoxications  following  the  action  of  these  somatic 
poisons  on  the  eliminating  and  other  organs  still  remain  to  be 
reckoned  with. 

On  the  other  hand,  the  synthetic  chemist  and  pharmacologist 
have  not  been  idle,  and  their  untiring  and  brilliant  efforts  to  find  sub- 
stitutes for  the  dangerous  and  costly  cocain  have  given  us  a  succes- 
sion of  remarkable  synthetic  products,  such  as  beta-eucain,  nirvanin, 
alypin,  stovain,  anesthesin,  etc.,  which  have  been  successively  dis- 
placed by  what  now  appears  to  be  the  nearest  approach  to  the  ideal 
local  analgesic — novocain. 

In  like  manner,  the  genius  of  synthetic  chemistry  and  the  bio- 
logic laboratory  have  found  in  suprarenin  a  less  perishable  substi- 
tute for  adrenalin,  the  active  product  directly  obtained  from  the 
gland.  The  advent  of  adrenalin  and  its  synthetic  substitutes  has 
marked  a  new  era  in  the  history  of  local  anesthesia.  By  its  powerful 
and  lasting  vasoconstrictor  and  ischemic  action  it  gives  the  operator 


INTRODUCTION  3 

a  bloodless  field,  which  has  deserved  for  it  the  name  of  the  "chemical 
tourniquet"  (Braun).  Combinations  of  novocain  and  adrenalin  in 
various  isotonic  dilutions — by  practically  eliminating  the  toxicity  of 
the  analgesic,  increasing  its  stability,  durability,  and  intensity — 
have  so  expanded  the  technic  that  in  the  hand  of  an  expert  peripheral 
analgesia  may  be  made  to  encompass  in  its  grasp  almost  the  entire 

domain  of  operative  surgery. 

*    *     * 

But  with  all  its  great  achievements  the  art  of  local  and  regional 
anesthesia  is  still  young.  Barely  three  decades  have  elapsed  since 
Karl  Koller  made  his  epochal  demonstration  of  the  anesthetic  prop- 
erties of  cocain  at  Heidelberg  in  1884,  and  yet,  in  spite  of  the  stupen- 
dous distance  that  we  have  traveled  since  then,  the  horizon  of  peripheral 
anesthesia  is  ever  widening  and  offering  new  opportunities  for  profitable 
exploitation.  It  is  still  in  process  of  development;  it  still  offers  many 
difficult  problems  that  await  solution. 

In  dealing  with  major  operations,  its  successful  application  de- 
mands patience,  time,  and  skill — a  skill  that  can  only  be  acquired 
and  exercised  on  the  human  cadaver  by  those  who,  being  anatomists, 
can  alone  survey  the  field  of  operation  with  fluoroscopic  eyes.  For 
this  reason  the  practice  of  peripheral  anesthesia,  especially  in  its 
neuroregional  aspects,  appeals  most  pointedly  to  the  young,  ambi- 
tious, and  well-trained  surgeon,  who,  fresh  from  the  anatomic  labora- 
tory, finds  here,  as  nowhere  else,  an  immediate  and  practical  applica- 
tion for  a  knowledge  that  he  has  acquired  at  the  cost  of  long  nights 
of  vigil,  labor,  and  thought. 

In  these  days  when  exact  topographic  and  applied  anatomy  is 
rated  somewhat  at  a  discount,  it  is  a  source  of  no  small  gratification 
for  the  young  but  well-trained  man  to  discover  that  his  anatomic 
knowledge  is  a  living,  palpable,  and  productive  asset.  Not  a  thing  to 
be  learned  solely  as  a  matter  of  academic  culture  and  soon  to  be  for- 
fotten,  but  a  practical  tool  to  be  used  in  unlocking  his  most  immediate 
technical  problems.  It  is  only  through  the  aid  of  applied  anatomy 
that  regional  anesthesia  is  what  it  is  to-day.  It  is  for  this  reason  that 
all,  or  nearly  all,  the  notable  advances  that  have  been  made  in  its 
technic  have  been  due  to  the  enterprise  and  the  activities  of  young 
surgeons.  Leonard  Corning,  Halsted,  Reclus,  Schleich,  Crile,  Gush- 
ing, Bier,  Oberst,  Braun,  and  a  host  of  others  who  have  laid  the  funda- 
mentals of  this  work  did  so  in  their  earlier  professional  years.  It  is 
this  same  potential  spirit  in  the  young  man  fresh  from  the  anatomic 
and  physiologic  laboratories  that  animates  their  followers — the 


4  INTRODUCTION 

builders  of  the  present  day.  Such  men  as  Offerhaus,  Hartel,  Peuckert, 
Hirschel,  Kulenkampf,  Danis,  Finsterer,  Lawen,  and  others  in 
Europe,  not  to  mention  a  group  of  young  surgeons  in  this  country 
and  in  our  own  immediate  surroundings — who  are  enriching  the 
foundation  laid  down  by  the  masters  by  their  contributions,  based 
chiefly  upon  anatomic  and  physiologic  researches. 

Whatever  may  be  the  limitations  of  regional  anesthesia  and  the 
objections  that  have  been  argued  against  it,  no  one  can  deny  that  it 
has  given  a  new  impetus  to  anatomic  teaching;  that  it  has  placed  a 
high  valuation  upon  an  exact  anatomic  training,  and  that  in  this  way 
it  is  making  it  less  possible  for  the  mere  cutter — the  "cut  and  tie" 
type  of  practitioner — to  be  confused  with  the  real  surgeon.  For  this 
reason  alone  it  deserves  the  encouragement  and  fostering  care  of 
every  surgeon  and  every  teacher  who  has  at  heart  the  higher  welfare 

of  his  science  and  his  art. 

*    *    * 

To  review  and  summarize  the  evidences  of  progress  in  local  and 
regional  analgesia;  to  study  and  analyze  the  copious  and  constantly 
growing  literature  which  is  rapidly  piling  up  to  pyramidal  and  almost 
inaccessible  heights;  to  scrutinize  the  various  analgesics  that  are  born 
yearly  in  the  laboratory  of  the  chemist,  and  try  the  methods  by  which 
they  may  be  utilized  with  special  advantage  in  the  different  regions 
of  the  body  and  in  connection  with  the  surgical  specialties;  to  gauge 
the  value  of  the  various  technics  proposed  by  the  criterion  of  clinical 
observation  and  personal  experience,  and,  in  a  like  manner,  to  judge  of 
their  advantages  and  limitations  in  their  relation  to  the  general 
narcosis,  was  a  task  which  I  had  set  to  myself,  and  which,  after  an 
experience  of  over  two  decades  in  this  mode  of  practice,  I  felt  might 
prove  profitable  to  the  profession,  if  only  in  the  interests  of  a  useful 
propaganda. 

But,  unfortunately,  many  circumstances  and  more  urgent  in- 
terests directed  my  attention  into  other  channels,  and  the  time  has 
never  come  when  I  could  sit  down  peacefully  and  calmly  to  the 
realization  of  my  project.  Fortunately  for  my  purpose,  the  seed 
sown  in  earlier  years  appears  to  have  yielded  good  and  seasonable 
fruit.  Associated  with  me  as  pupils  and  assistants  were  a  group  of 
young  men  who  entered  into  the  spirit  of  the  work  with  zeal  and 
enthusiasm.  The  results  obtained  in  our  clinics  and  exhibited  in 
our  reports  of  1900,  and  subsequently,  have  been  made  possible 
largely  through  their  faithful  collaboration.  Several  of  these  have 
already  attained  enviable  reputations  in  our  community  and  else- 


INTRODUCTION  5 

where,  as  teachers  and  surgeons  especially  skilled  in  the  methods  of 
local  and  regional  anesthesia,  and  to  all  these  I  owe  a  debt  of  grati- 
tude. Conspicuous  among  these  is  Dr.  Carroll  W.  Allen,  whose 
steadfast  loyalty  to  these  methods  for  many  years  has  been  rewarded 
by  a  reputation  for  special  skill  and  judgment  in  their  application 
which  is  eminently  deserved.  He  has  assiduously  cultivated  the 
technic  in  all  its  variations,  many  of  which  are  his  own,  and  in  our 
joint  services  at  the  Charity  Hospital  the  results  obtained  have 
proved  so  satisfactory  that  fully  55  or  60  per  cent,  of  the  major  opera- 
tions in  the  division  under  his  charge  are  performed  solely  by  periph- 
eral anesthetic  procedures,  exclusive  of  the  spinal  or  subarachnoid 
analgesias  which  are  not  included  in  this  category.  One  of  the  best 
proofs  of  the  success  of  any  method  of  practice  is  the  confidence  it 
inspires  among  the  men  of  the  profession  and  in  their  willingness  to 
have  it  applied  to  themselves.  Schleich,  in  his  "Schmerzlose  Opera- 
tionen,"  tells  us  how  his  clinic  was  besieged  by  doctors  who,  needing 
surgical  relief  for  various  ailments,  were  anxious  to  be  operated  on  by 
him  painlessly,  but  without  the  unconsciousness  of  general  narcosis. 
This  is  the  experience  of  every  operator  whose  reputation  for  skill  in 
local  and  regional  methods  is  confirmed  by  his  results.  Dr.  Allen  is 
no  exception  to  this  rule. 

Now,  returning  to  the  book.  I  had  almost  abandoned  all  expecta- 
tion of  accomplishing  this  self-appointed  task  when  Dr.  Allen  gener- 
ously offered  his  collaboration.  I  had  hoped  that  this  valued  offer 
would  have  made  the  task  lighter.  Dr.  Allen  set  himself  seriously 
and  earnestly  to  work  and  gathered  a  large  mass  of  material  which  I 
found  it  impossible  to  edit  with  him  without  the  sacrifice  of  other  and 
more  pressing  obligations,  or  subjecting  the  publishers  to  unwar- 
ranted delays.  All  that  I  could  do  was  to  give  him  the  full  and  free 
use  of  my  previous  writings  and  original  observations  on  this  subject 
and  such  general  counsel  as  my  experience  dictated.  This  volume 
as  it  stands  is,  therefore,  the  result  of  Dr.  Allen's  sole  industry,  thought, 
and  labor.  My  regret  is  that  I  have  not  been  able  to  join  forces  with 
him  in  accomplishing  a  task  which  it  was  my  privilege  to  initiate  even 
though  indirectly,  and  in  which  I  have  always  had  a  deep  and  abiding 
interest.  Without  having  had  an  opportunity  to  revise  the  text  or 
to  read  it  thoroughly — through  no  fault  of  Dr.  Allen  or  lack  of  willing- 
ness on  my  part — I  am  satisfied,  by  many  years  of  professional  and 
friendly  association  with  the  author,  that  the  methods  and  teachings 
expounded  for  the  last  twenty  years  in  the  surgical  clinics  of  the 
Tulane  University  will  not  only  be  well  represented,  but  will  be 


6  INTRODUCTION 

strengthened,    and    thereby   diffused    over    a   greater    and   growing 
area. 

If  Dr.  Allen's  book  will  only  encourage  others  to  follow  his  ex- 
ample, and  stimulate  his  contemporaries,  and  especially  the  young 
surgeons  of  the  rising  generation,  to  cultivate  the  "qualities  of  head, 
heart,  and  hand"  that  are  necessary  for  the  successful  practice  of  the 
art  of  peripheral  anesthesia,  it  will  have  served  a  useful  purpose  and 
discharged  a  worthy  mission.  In  this  hope  I  wish  it  God-speed. 

RUDOLPH  MATAS. 


PREFACE  TO  THE  SECOND  EDITION 


DURING  the  three  years  that  have  elapsed  since  the  appearance 
of  the  first  edition  of  this  book  some  improvement  and  progress  has 
been  made  in  the  field  of  local  anesthesia. 

With  a  general  broadening  of  this  field  many  additional  opera- 
tions have  been  added  to  the  already  long  list  of  those  commonly 
performed  by  surgeons  skilled  in  the  use  of  these  methods.  Notable 
among  these  additions  is  the  removal  of  the  prostate,  a  subject 
upon  which  I  have  worked  for  some  years  and  which  was  but  briefly 
touched  upon  in  the  first  edition  as  there  were  many  details  not  yet 
perfected  at  that  time. 

I  regard  the  removal  of  the  prostate  as  my  best  accomplishment 
in  local  anesthesia;  this  is  largely  on  account  of  the  great  reduction 
of  mortality  and  the  ease  with  which  it  is  done  by  these  methods. 
It  is  particularly  in  these  subjects  that  general  anesthesia  is  so  much 
to  be  dreaded. 

The  addition  of  sacral  anesthesia  and  some  practical  additions 
to  abdominal  surgery  are  among  the  recent  advances. 

Many  valuable  and  useful  additions  will  be  found  in  the  chapter 
on  the  head;  the  progress  here  has  been  very  marked.  Much  of  the 
text  has  been  rearranged,  and  the  chapter  on  spinal  anesthesia  has 
been  largely  rewritten. 

Every  change  is  not  always  a  reform  and  apparent  triumph  is  not 
always  progress.  There  is  often  work  that  must  be  done  without 
enthusiasm,  work  that  brings  only  unrelieved  weariness  and  a  plod- 
ding gait,  but  the  direct  value  of  what  we  do  is  that  we  are  working 
in  the  direction  of  progress.  This  has  been  my  inspiration  and  with 
these  thoughts  in  mind  I  send  this  edition  to  press. 

CARROLL  W.  ALLEN. 

NEW  ORLEANS,  LA., 

Marck,  1918. .  7 


PREFACE 


IN  presenting  this  volume  to  the  profession  I  have  hoped  to  fill 
what  I  have  learned  by  my  experience  as  a  teacher  is  a  real  want  in 
the  surgical  literature  of  the  English  language. 

Many  small  monographs  have  been  available  for  the  general 
surgeon,  and  some  excellent  books  dealing  exclusively  with  the  spe- 
cialties have  been  published,  but  no  book  in  our  language  has  at- 
tempted to  survey  the  entire  field,  giving  the  essential  elements  in 
the  successful  application  of  local  anesthesia  to  major  surgery,  as 
well  as  a  systematic  and  detailed  description  of  the  methods  of  anes- 
thesia suitable  to  operations  in  the  different  regions  of  the  body. 
The  excellent  work  of  Professor  Heinrich  Braun  is  a  masterpiece 
and  a  model  of  German  thoroughness  and  comprehensiveness,  and 
I  have  availed  myself  of  this  fountain  source  of  information  in  both 
text  and  illustrations  through  the  courtesy  of  Professor  Braun  him- 
self and  of  his  obliging  publisher,  Herr  J.  A.  Barth. 

When  this  volume  was  first  undertaken  it  was  intended  that  it 
should  be  a  joint  contribution  from  Professor  Rudolph  Matas  and 
myself,  an  accomplishment  of  which  I  would  truly  have  been  proud; 
however,  lack  of  time  and  the  urgent  press  of  other  duties  forced 
Doctor  Matas  to  withdraw  his  direct  collaboration,  leaving  to  me  the 
responsibility  of  this  publication. 

I  feel  it  is  fitting  that  a  pupil  and  close  associate  of  his  should 
assume  this  task.  It  was  at  his  side  that  I  received  my  first  lesson 
in  local  anesthesia,  and  derived  from  him  that  enthusiasm  and  zeal 
for  the  work  that  has  made  this  book  possible.  It  was  his  hand 
that  opened  the  door  to  my  surgical  career,  and  from  that  hand  I 
have  received  a  generous  bounty  since.  His  name  will  always  be 
numbered  among  the  pioneers  of  local  and  regional  anesthesia — with 
Corning,  Halsted,  Crile,  and  Gushing  in  this  country;  Schleich,  Braun, 
Reclus,  and  Barker  abroad. 

While  deprived  of  his  collaboration  in  the  authorship  of  this 
work,  I  have  quoted  liberally  from  his  writings  and  drawn  still  more 
liberally  from  his  ideas  and  spoken  teachings  on  this  subject.  To 

9 


10  PREFACE 

him  is  due  the  credit  of  working  out  successfully  the  first  route  to 
the  second  division  of  the  trigeminus  and  blocking  it  with  Meckel's 
ganglion  and  its  branches,  through  the  sphenomaxillary  fissure  and, 
in  this  way,  painlessly  resecting  the  upper  maxilla,  a  method  which 
by  German  authors  is  still  erroneously  credited  to  Payr.  The  Germans 
(Braun,  Hartel,  et  al.),  however,  credit  Matas  with  the  inframalar 
route  for  reaching  the  inferior  maxillary  division  at  the  foramen  ovale 
to  which  they  have  attached  his  name.  With  the  aid  of  this  proced- 
ure he  had  resected  the  lower  jaw  many  times,  long  before  Schlosser 
had  popularized  this  route  for  the  alcoholization  of  this  nerve  in 
trifacial  neuralgia.  Matas  first  worked  out  a  satisfactory  method  of 
regional  anesthesia  of  the  forearm  by  blocking  the  nerves  at  the 
elbow,  and,  independently  of  Crile's  earlier  work,  he  had  amputated 
the  leg  and  thigh  several  times  by  blocking  the  sciatic,  anterior  crural, 
obturator,  and  saphenous  nerves.  He  performed  the  first  operation 
under  spinal  analgesia  in  America,  and  devised  several  types  of  ap- 
paratus for  massive  infiltration  anesthesia.  Such  terms  as  "intra- 
neural,"  "perineural,"  and  "paraneural,"  as  applied  to  regional 
neural  methods,  were  first  introduced  by  him,  as  acknowledged  by 
Braun,  at  a  time  when  such  niceties  of  classification  were  unknown 
in  the  literature. 

The  earlier  accomplishments  of  Matas  in  this  field  have  been  over- 
shadowed by  his  later  and  far-reaching  contributions  to  other  depart- 
ments of  surgery,  more  particularly  the  various  operations  for  the 
radical  cure  of  aneurysm  which  are  permanently  linked  with  his  name. 
In  this  way,  his  work  in  anesthesia  has  been  overlooked  or  forgotten 
by  many,  who  aware  only  of  the  marvelous  efficiency  of  this  branch 
of  surgery  at  the  present  time,  are  oblivious  of  the  laborious  steps 
that  have  led  to  its  present  evolution.  I  feel  it  a  fitting  task,  there- 
fore, that  the  recital  of  Professor  Matas'  early  achievements  as  they 
appear  in  the  following  pages  should  devolve  upon  me. 

The  fundamental  work  on  "nerve-blocking,"  which  has  so  intimately 
and  inseparably  associated  the  name  of  Crile  with  the  early  history 
of  regional  anesthesia,  is  now  supplemented  by  his  epoch-making 
studies  in  anoci-association  and  in  their  practical  application.  The 
growing  appreciation  of  these  principles  has  made  a  thorough  knowl- 
edge of  local,  and  especially  regional,  analgesia  more  than  ever  neces- 
sary to  the  progressive  surgeon  who  would  follow  the  teachings  of 
this  eminent  leader. 

A  very  extensive  bibliography  had  been  prepared  upon  which  the 
author  had  expended  much  time  and  laborious  research;  it  was  in- 


PREFACE  I I 

tended  as  an  appendix  to  the  volume,  which  would  have  been  of  service 
to  the  student  of  the  history  and  literature  of  the  subject.  It  em- 
braced a  list  of  over  six  thousand  references,  covering  several  hundred 
pages.  Unfortunately,  as  the  text  grew  in  size,  it  was  found  that 
even  an  abridged  bibliography  would  have  so  far  exceeded  the  pro- 
posed dimensions  of  the  volume  that  it  would  have  been  too  ponder- 
ous for  the  purpose  for  which  it  was  originally  intended.  At  the  sugges- 
tion of  the  publishers  it  was  deemed  best  to  abandon  this  publication,  a 
determination  which  has  been  a  sore  disappointment  to  the  author, 
who  in  this  way  had  expected  to  make  a  full  acknowledgment  of 
every  publication  referred  to  in  the  text;  as  it  is,  many  important 
references  have  been  regretfully  omitted. 

The  author  now  desires  to  express  his  special  and  grateful  obliga- 
tion to  the  many  authors  and  investigators  quoted,  whose  writings 
have  so  largely  and  generously  contributed  to  the  making  of  this 
book. 

In  the  preparation  of  this  volume  I  am  under  particular  obliga- 
tion to  my  friend,  Professor  M.  Feingold,  for  valuable  assistance 
and  advice  in  the  chapter  on  the  Eye  as  well  as  in  the  general  text; 
to  Professor  C.  J.  Lanfried  for  assistance  in  the  chapter  on  the 
Ear,  Nose,  and  Throat;  to  Drs.  E.  C.  Samuel  and  R.  M.  Blakely, 
of  Touro  Infirmary,  for  their  kind  assistance  in  the  illustrations;  and 
to  Miss  L.  Ambrose  for  her  assistance  in  the  translations.  I  am  also 
much  indebted  to  Professors  Arthur  E.  Barker,  of  London;  Fritz 
Hartel,  of  Berlin;  and  Guido  Fischer,  of  Marburg,  for  the  privilege  of 
making  many  quotations  and  the  use  of  valuable  illustrations. 

CARROLL  W.  ALLEN. 

NEW  ORLEANS,  LA. 


CONTENTS 


CHAPTER  I 

PAGE 

HISTORY 17 

CHAPTER  II 

NERVES  AND  THEIR  SENSATIONS — ESPECIALLY  PAIN 26 

Distribution  of  Sensation 37 

Philosophy  of  Pain 44 

CHAPTER  III 

OSMOSIS  AND  DIFFUSION 46 

CHAPTER  IV 

THE  ANESTHETIC  EFFECTS  OF  PRESSURE- ANEMIA — COLD  AND  WATER  ANESTHESIA  58 

Pressure 58 

Cold 60 

Water  Anesthesia 63 

CHAPTER  V 

LOCAL  ANESTHETICS 67 

t  Cocain 72 

Eucain 77 

Akoin 81 

Holocain 81 

Tropacocain 82 

Stovain 83 

Alypin 83 

Novocain  Hydrochloric! 85 

Chloretone 89 

Orthoform 92 

Nirvanin 93 

Anesthesin 93 

Subcutin 95 

Propasin 96 

Apothesine 96 

Comparative  Action  of  Anesthetic  Agents 99 

Toxicity 104 

Anesthetic  Properties  of  Quinin  Salts 109 

Anesthetic  Properties  of  Magnesium  Salts 123 

13  « 


14  CONTENTS 

CHAPTER  VI 

PAGE 

TOXICOLOGY 125 

CHAPTER  VII 

ADRENALIN „ 137 

Surgical  Uses 148 

CHAPTER  VIII 

PRINCIPLES  OF  TECHNIC 155 

General  Considerations 155 

Solutions  and  Their  Methods  of  Use 158 

Classification  of  Methods  of  Local  and  Regional  Anesthesia  in  which  Cocain 

and  Other  Allied  Analgesic  Drugs  are  Utilized  as  the  Active  Agents 161 

The  Armamentarium 1 73 

Clinical  Application 1 76 

Cold 181 

Regional  Anesthesia 182 

The  Constrictor 186 

Technic  of  Handling  Wounds  in  General 187 

Hemostasis  and  Closure  of  Wounds 190 

The  History  of  the  Hypodermic  Syringe i  go 

CHAPTER  IX 

THE    USE    OF  MORPHIN  AND    SCOPOLAMIN  AND   .COMBINED  METHODS  OF    AN- 
ESTHESIA    192 

Morphin  and  Scopolamin 192 

Combined  Methods  of  Anesthesia 198 

CHAPTER  X 

INDICATIONS,  CONTRA-INDICATIONS,  AND  SHOCK 201 

Indications  and  Centra-indications 201 

Shock 202 

CHAPTER  XI 

ANOCI-ASSOCIATION 204 

CHAPTER  XII 

INTRA-ARTERIAL  ANESTHESIA 211 

Intravenous  Anesthesia 217 

CHAPTER  XIII 

GENERAL  ANESTHESIA  THROUGH  THE  INTRAVENOUS  INJECTION  or  LOCAL  ANES- 
THETICS. .                                                                                                                  221 


CONTENTS  15 

CHAPTER  XIV 

PAGE 

THE  UPPER  AND  LOWER  EXTREMITIES 224 

Bones  and  Joints 225 

The  Brachial  Plexus 227 

Nerves  of  the  Upper  Extremity 238 

The  Fingers  and  Hand 245 

The  Lower  Extremity 257 

The  Hip  and  Thigh 267 

The  Knee-joint 270 

The  Leg 272 

CHAPTER  XV. 

THE  NECK 279 

Operations  on  the  Neck 283 

The  Larynx  and  Trachea 287 

Goiter 291 

CHAPTER  XVI 

THE  THORAX  AND  BACK 302 

The  Sternum 312 

The  Back 312 

CHAPTER  XVH 

THE  ABDOMEN 317 

Possible  Scope  of  Operations  within  the  Abdomen 349 

CHAPTER  XVin 

HERNIA 359 

Inguinal  Hernia 360 

Femoral  Hernia 372 

Umbilical  Hernia 374 

Postoperative  Hernia 376 

CHAPTER  XIX 

GENITO-URINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS 379 

Genito-urinary  Organs 379 

Penis , 383 

Scrotum 389 

Chancroids 393 

Bladder 394 

Prostatectomy 395 

The  Kidney  and  Ureter 4°7 

Anorectal  Region 411 

Gynecologic  Operations 4 20 


I 6  CONTENTS 

CHAPTER  XX 

PAGE 

SPINAL  ANALGESIA 432 

Anatomy 435 

Anesthetic  Agents 436 

Isotonic  Qualities  and  Specific  Gravity  of  Anesthetic  Solutions  and  Their 

Movements  within  the  Canal 439 

Indications  and  Centra-indications 450 

Technic 453 

Failures ". 463 

In  Obstetrics  and  Gynecolog> 464 

Military  Surgery 465 

Physiological  Action 466 

Vascular  System 467 

Respiration 468 

Abdomen 469 

After-effects 470 

Experimental  Work 472 

Urinary  Changes 476 

Effects  on  the  Nervous  System 477 

Ocular  Palsies 481 

The  Method  of  Jonnesco , 484 

Treatment  of  After-effects 485 

Epidural,  Caudal  or  Sacral  Anesthesia 486 

CHAPTER  XXI 

PARAVERTEBRAL  AND  PARASACRAL  ANESTHESIA 494 

Paravertebral  Anesthesia 494 

Parasacral  Anesthesia 5°2 

CHAPTER  XXII 

THE  HEAD,  SCALP,  CRANIUM,  BRAIN,  AND  FACE 507 

The  Face 528 

Internal  Maxillary  Artery 60 1 

CHAPTER  XXIII 

THE  ORGANS  or  SPECIAL  SENSE,  WITH  DENTAL  ANESTHESIA 625 

The  Eye 625 

The  Ear .......  630 

Nose  and  Throat 634 

Dental  Anesthesia 644 


INDEX  . .  663 


LOCAL  ANESTHESIA 


CHAPTER  I 
HISTORY 

Divinum  est  opus  sedare  dolorem  (divine  is  the  work  to  relieve 
pain).  Thus  spoke  Hippocrates. 

The  history  of  the  efforts  of  the  human  race  to  find  a  means  to 
control  pain  during  operative  procedure  forms  one  of  the  most  inter- 
esting chapters  in  medicine.  The  writings  of  authors,  from  earliest 
antiquity  down  through  the  long  centuries,  deal  with  efforts  in  be- 
half of  human  suffering.  Sometimes  surrounded  by  superstitions  at 
times  the  most  ridiculous;  later,  as  knowledge  increased,  based  upon 
more  or  less  reason,  but  all  futile  and  attaining  the  desired  end  only 
to  a  limited  degree. 

Among  the  earlier  references  to  the  use  of  narcotics  is  to  be  found 
the  following  from  Homer's  "Odyssey,"  when  Helen  gave  to  Ulysses 
and  his  comrades  the  "sorrow  easing  drug,"  which  probably  con- 
sisted of  the  juice  of  the  poppy  and  Indian  hemp: 

"Presently  she  cast  a  drug  into  the  wine,  whereof  they  drank — 
a  drug  to  lull  all  pain  and  anger  and  bring  forgetfulness  of  every 
sorrow.  Whoso  should  drink  a  draught  thereof,  when  it  is  mingled 
in  the  bowl,  on  that  day  he  would  let  no  tear  fall  down  his  cheek,  not 
though  his  mother  and  father  died,  not  though  men  slew  his  brother 
or  dear  son  with  the  sword  before  his  face  and  his  own  eyes  beheld  it." 

During  the  siege  of  Troy  the  Greek  surgeons  used  anodyne  and 
astringent  applications  to  ease  the  pain  of  their  wounded,  which 
probably  had  some  antiseptic  effect  of  which  they  were  not  aware. 

The  following  is  found  in  the  "Iliad,"  when  Patroclus,  in  admin- 
istering to  the  sufferings  of  Euryphylus,  removed  a  dagger  from  his 
thigh: 

"Cut  out  the  biting  shaft;  and  from  the  wound 
With  tepid  water  cleansed  the  clotted  blood;  r 

Then,  pounded  in  his  hands,  the  root  applied 
Astringent,  anodyne,  which  all  his  pain 
Allay'd;  the  wound  was  dried,  and  stanched  the  blood." 

2  17 


1 8  LOCAL   ANESTHESIA 

It  is  probable  that  primitive  men  used  pressure  and  cold  to  be- 
numb the  parts  and  thus  lessen  pain.  In  time  they  no  doubt  learned 
that  pressure  over  the  region  of  the  nerves  and  arteries  had  a  more 
pronounced  effect,  though  they  probably  did  not  know  why.  The 
ancient  Assyrians  employed  pressure  over  the  carotids  and  produced 
a  certain  degree  of  anesthesia  by  cutting  off  the  blood-supply  to  the 
brain,  and  performed  their  operation  of  circumcision  in  this  way. 
The  aboriginal  natives  of  some  countries  practice  this  method  to-day. 
That  this  practice  must  have  been  widespread  is  borne  out  by  the 
fact  that  the  literal  translation  of  the  Greek  and  Russian  names  of 
the  carotid  artery  is  "the  artery  of  sleep." 

The  ancient  Egyptians  used  the  juice  of  the  poppy  and  Indian 
hemp  before  surgical  operations.  They  also  used  a  certain  kind  of 
"Stone  of  Memphis,"  which  was  supposed  to  have  special  virtues, 
and  was  probably  a  carbonated  rock.  This  they  wet  with  sour  wine 
and  applied  it  to  the  wound  or  the  region  to  be  operated  upon,  thus, 
no  doubt,  generating  carbonic  acid  gas.  Accounts  do  not  say  whether 
they  were  aware  of  this  chemical  reaction  or  knew  the  action  of 
carbonic  acid  gas.  The  Egyptians  also  used  the  fat  of  the  "holy 
animal  of  the  land,"  the  crocodile,  or  its  dried  and  powdered  skin, 
to  produce  local  anesthesia.  What  results  were  obtained  by  these 
methods  is  not  known,  but  they  were  nearly  always  combined  with 
the  internal  administration  of  alcoholics  and  narcotics  in  use  at  that 
time. 

Gold  and  silver  instruments  were  supposed  to  cause  less  pain  than 
others;  also  warmed  and  greased  instruments.  This  practice  was 
made  use  of  in  later  times.  It  is  stated  that  Lord  Nelson  was  so 
painfully  affected  by  the  chill  of  the  surgeon's  knife  when  his  right 
arm  was  amputated  at  Teneriffe,  that  at  the  Battle  of  the  Nile  he 
ordered  his  surgeons  to  keep  hot  water  ready  to  warm  their  knives 
before  using  them. 

The  ancient  Greeks  also  knew  of  the  sedative  and  anodyne  proper- 
ties of  many  plants,  from  which  they  made  ointments  and  lotions. 
Aphrodite  is  said  to  have  thrown  herself  on  a  bed  of  lettuce  and 
mandragora  to  lessen  her  feelings  of  grief  over  the  death  of  Adonis. 

There  is  probably  no  medicinal  plant  with  which  was  associated 
more  ridiculous  and  absurd  superstition  than  Mandragora  atropa. 
Much  of  this  superstition  no  doubt  grew  out  of  its  fancied  resem- 
blance to  parts  of  the  human  body,  and  the  more  accurate  this  re- 
semblance, the  more  highly  was  it  valued.  The  growth  of  this  plant 
must  have  been  widely  distributed  throughout  Europe,  Asia,  and 


HISTORY  19 

Africa,  for  it  was  used  by  all  of  the  ancient  races.  The  Babylonians 
used  it  two  thousand  years  before  Christ.  The  ancient  Egyptians, 
Hebrews,  Hindus,  and  Chinese  all  used  it. 

The  Chinese  early  recognized  the  local  anesthetic  action  of  many 
drugs.  Certain  subjective  tribes  were  made  to  pay  their  tribute  in 
such  plants.  In  the  middle  of  the  twelfth  century  a  pupil  of  the 
Salernitana  School  wrote  a  treatise  on  the  local  sedative  action  of 
opium,  mandragora,  and  hyoscyamus.  Even  up  to  comparatively 
recent  times  many  native  Chinese  surgeons,  who  knew  of  the  dis- 
covery of  chloroform,  continued  to  practice  anesthesia  by  the  older 
methods.  Fat,  marrow,  and  lizard  oil  were  also  used  by  the  Chinese, 
who  attributed  to  them  certain  sedative  action. 

Freezing  by  the  use  of  ice  or  snow  was  sometimes  resorted  to  to 
produce  local  anesthesia,  thus  foreshadowing  the  use  of  ether  and 
ethyl  chlorid  for  this  purpose.  Thomas  Bartholinus,  a  pupil  of  the 
Neapolitan  anatomist,  Marcus  Aurelio,  first  introduced  it  in  the 
middle  of  the  sixteenth  century. 

At  times  many  methods  were  forgotten  and  again  revived.  In 
the  middle  ages  pressure,  which  seemed  to  have  been  forgotten,  was 
again  brought  into  use.  Constrictors  were  then  first  used  to  deaden 
the  sensibility  of  the  parts  by  cutting  off  the  circulation  and  to  pre- 
vent hemorrhage  after  amputation.  Velpeau  later  recommended  it. 

In  1784  J.  Moore,  of  England,  devised  a  constricting  apparatus 
which,  when  left  in  place  one  and  a  half  hours,  combined  with  the  use 
of  large  doses  of  morphin,  permitted  painless  peripheral  operations. 
Moore's  apparatus  produced  a  high  grade  of  venous  stasis,  and, 
through  many  failures,  fell  into  disuse  and  was  forgotten. 

In  the  middle  of  the  last  century  Esmarch  introduced  his  con- 
strictor and  bloodless  method  of  operating,  which  was  soon  adopted 
in  all  countries,  and  is  the  same  as  is  in  use  to-day. 

Cold,  like  other  anesthetic  methods,  was  forgotten,  but  revived 
again  by  J.  Hunter,  who  carried  out  painless  experiments  on  animals. 

Larrey,  Napoleon's  chief  surgeon,  reported  that  at  the  battle  of 
Eylau  in  1807,  with  a  temperature  of  —  i9°F.,  amputations  were 
almost  painless.  Later,  through  the  observations  of  Arnott  in  1848, 
Guerard  and  Richet,  1854,  but  especially  through  Richardson,  1866, 
was  the  refrigerating  of  the  tissues  for  surgical  purposes  put  upon  a 
firm  foundation  by  the  use  of  ether  sprays. 

Percival  in  1772  discovered  the  anesthetic  properties  of  carbonic 
acid  gas  when  sprayed  on  a  raw  or  denuded  surface,  but  it  was  found 
to  have  little  or  no  action  on  the  intact  epidermis. 


20  LOCAL   ANESTHESIA 

The  electric  current  was  first  used  in  the  middle  of  the  last  century 
to  produce  local  anesthesia  through  cataphoresis  with  various  drugs. 

The  discovery  of  the  hypodermic  syringe  by  F.  Rynd,  of  Edin- 
burgh in  1845,  though  erroneously  attributed  to  Wood,  marked  the 
beginning  of  a  new  era.  Morphin  solutions  and  tincture  of  opium 
were  injected  into  the  tissues  and  around  nerve-trunks  with  the  idea 
of  deadening  them,  but,  while  these  agents  possess  some  slight  local 
anesthetic  action,  any  decided  effect  which  was  obtained  was  due  to 
their  general  action ;  however,  many  operations  were  performed  under 
their  use,  administered  in  this  way,  and  are  reported  as  having  been 
comparatively  painless. 

Other  substances,  such  as  chloroform,  which  also  has  slight  local 
anesthetic  action,  were  similarly  used,  but  the  irritating  results  of 
their  injection  soon  caused  them  to  be  abandoned. 

The  introduction  of  general  anesthesia  about  this  time,  instead 
of  lessening  the  interest  in  local  anesthesia,  seemed  only  to  intensify 
the  efforts  and  increase  the  zeal  of  those  engaged  in  the  search  for 
a  safe  and  efficient  local  anesthetic;  these  labors  were  soon  to  be 
rewarded. 

The  first  cocain  was  obtained  from  the  coca  leaves,  but  later  was 
prepared  synthetically.  The  first  report  of  the  anesthetic  properties 
of  cocain  was  when  Scherzir  reported  anesthesia  of  the  tongue  after 
chewing  the  leaves. 

Godeke,  as  early  as  .1855,  had  isolated  a  principle  from  the  leaves 
of  the  plant,  which  he  called  erythroxylin.  A  few  years  later  Nie- 
mann,  in  a  further  investigation  of  its  action,  noticed  that  it  produced 
numbness  of  the  tongue,  both  when  the  leaves  were  chewed  and  when 
the  alkaloid  was  placed  on  the  tongue.  He  first  gave  the  name  cocain 
to  the  active  principal. 

In  1874  Bennet  demonstrated  that  cocain  possessed  anesthetic 
properties. 

Von  Anrep  in  1879  made  a  thorough  investigation  of  the  drug, 
and  used  it  hypodermically  upon  himself,  injecting  a  weak  solution 
under  the  skin  of  his  arm,  and  found  that  it  first  produced  a  sense 
of  warmness,  followed  by  anesthesia.  The  stick  of  the  needle  at  this 
point  no  longer  gave  pain.  The  anesthesia  lasted  about  thirty-five 
minutes.  In  his  discussion  he  suggests  the  possibility  of  its  being 
used  as  a  local  anesthetic  for  surgical  purposes. 

Cocain  had  already  been  known  as  a  mydriatic,  but  Coupard  and 
Borderon  in  1880  discovered  its  local  anesthetic  action  when  dropped 
into  the  eye. 


HISTORY  21 

Karl  Roller  undertook  a  series  of  experiments  on  animals  in  Prof. 
Sticker's  laboratory,  and  demonstrated  the  complete  anesthesia  of 
the  eye  by  the  use  of  a  2  per  cent,  solution.  The  anesthesia  lasted, 
on  an  average,  ten  minutes.  This  was  followed  in  1884  by  his 
announcement  at  the  Ophthalmological  Congress  at  Heidelberg. 

The  tremendous  value  of  this  discovery  soon  led  to  the  universal 
use  of  the  drug  in  ophthalmic  operations  all  over  the  civilized  world. 
Its  use  soon  spread  to  other  fields,  and  was  applied  to  the  mucous 
membrane  of  the  nose,  throat,  and  larynx,  with  gratifying  success  as 
an  anesthetic. 

"  Within  the  short  period  of  twelve  months  the  newly  discovered 
properties  of  the  drug  had  been  tested  in  every  important  clinic  of 
the  world,  and  the  utility  of  cocain  as  a  surface  anesthetic  had  been 
put  to  trial  in  every  form  of  intervention  in  which  the  insensibility 
of  exposed  or  accessible  mucous  or  cutaneous  surfaces,  could  serve  the 
purpose  of  the  surgical  specialist  or  therapeutist.  Thus  it  happened 
that,  within  an  incredibly  short  space  of  time,  a  new  literature  sprang 
into  existence,  in  which  was  reflected  the  experiences  of  ophthalmolo- 
gists, otologists,  stomatologists,  dermatologists,  genito-urinary  sur- 
geons, gynecologists,  and  obstetricians"  (Matas). 

Untaught  by  experience,  and  too  early  yet  for  experimentation  to 
have  shown  the  toxicity  of  the  potent  yet  dangerous  drug,  many 
cases  of  poisoning  and  death  naturally  followed  its  use  in  concen- 
trated solutions  and  in  large  quantities. 

Owing  to  the  importance  of  this  drug,  the  first  and  representative, 
as  well  as  the  standard  to  which  similar  agents  are  compared,  it 
seems  that  a  few  remarks  regarding  its  early  history  may  prove 
desirable. 

The  plant  formerly  played  a  large  part  in  the  religious  rites  of  the 
natives  of  Peru.  It  was  considered  as  a  heavenly  gift,  which  "satis- 
fied the  hungry,  gave  life  to  the  tired  and  exhausted,  and  made  the 
unfortunates  forget  their  troubles"  (Novinny).  Those  forced  to 
heavy  labor  or  long,  fatiguing  journeys  found  exhilaration  and  stimu- 
lation by  chewing  the  leaves.  During  the  time  of  the  Incas  its 
cultivation  was  controlled  by  the  royal  family,  who  levied  a  tax  on 
its  production.  When  Pizarro  invaded  the  country  in  1532  he  found 
its  use  widely  distributed  and  much  abused  by  excessive  use.  After 
conquering  the  country  the  Spaniards  first  forbade  its  culture,  but 
later  monopolized  it  and  levied  a  heavy  tax  upon  its  cultivation. 

The  leaves  in  use  by  the  natives  are  obtained  from  cultivated 
plants,  the  wild  leaves  are  unfit  for  use;  its  cultivation  is  generally 


22  LOCAL   ANESTHESIA 

like  that  of  coffee  and  tea  shrubs.  It  is  now  more  particularly  culti- 
vated in  Bolivia,  and  large  quantities  are  exported  to  Peru.  Other 
varieties  of  the  plant  grow  in  most  South  American  countries — 
Mexico,  India,  and  Java. 

The  coca  bush  grows  from  5  to  8  feet  in  height  and  is  widely 
branched,  its  flower  is  white  or  cream  colored,  and  grows  in  little 
fascicles,  close  against  the  bark  on  the  older  and  leafless  part  of  the 
twigs.  There  is  no  particular  season  for  gathering  the  leaves,  which 
are  picked  when  they  reach  a  certain  degree  of  maturity.  The  first 
crop  can  be  gathered  after  about  two  and  a  half  years  from  plants 
grown  from  the  seed,  and  continue  to  bear  for  about  twenty  to  thirty 
years.  The  leaves  are  picked  by  hand  and  dried  in  the  sun,  and  must 
be  kept  absolutely  free  from  wetting  by  rain  or  other  moisture.  Con- 
siderable care  is  necessary  for  their  proper  curing,  as  much  deteriora- 
tion may  result  when  improperly  done,  resulting  in  change  of  taste, 
due  probably  to  the  formation  of  other  products  in  the  leaf. 

In  the  countries  in  which  the  plant  is  indigenous  the  lower  classes 
still  chew  the  leaves,  but  the  better  classes  drink  it  when  prepared  as 
a  kind  of  cordial,  liquor,  or  pousse  cafe. 

There  are  several  varieties  of  the  plant — the  Huanuco  or  Bolivian 
leaf,  the  Peruvian  and  Truxillo  varieties — all  varying  slightly  in  some 
particulars,  as  regards  to  size  and  shape  of  leaf,  as  well  as  to  their 
value  therapeutically.  In  a  general  way  the  leaf  is  about  i  to  3 
inches  in  length,  and  from  %  to  i^  inches  in  breadth,  and  of  oval 
shape.  There  is  not  much  doubt  that  the  species  originated  upon 
the  eastern  slope  of  the  Andes,  probably  in  Peru,  where  it  grows  wild 
and  has  lost  some  of  its  cultivated  characteristics. 

The  following  history  of  the  plant  is  quoted  from  Rusby's  article 
in  the  Reference  Handbook  Medical  Sciences,  1901 : 

"The  coca  plant  was  under  cultivation  at  the  time  of  the  discov- 
ery, and  no  clew  to  its  introduction  to  cultivation  could  then  be,  or 
has  since  been,  obtained.  It  occupied  an  important  place  in  the 
religious  and  mythologic  history  of  the  people.  This  is  of  interest 
here  only  because  of  the  unquestionable  fact  that  such  esteem  was 
the  result  of  an  appreciation  of  its  useful  properties  rather  than,  upon 
the  contrary,  and  as  for  centuries  believed,  the  superstitious  reason 
for  its  being  used. 

"We  may,  therefore,  dismiss  its  mythical  history  (see  'Coca  at 
Home  and  Abroad,'  Ther.  Gaz.,  March  and  May,  1888;  also  p.  14, 
1886)  as  being  here  unimportant,  and  consider  its  physiologic  and 
therapeutic  history.  Its  expectorant,  sialogogue,  stomachic,  carmina- 


HISTORY  23 

live,  emmenagogue,  and  aphrodisiac  properties  are  among  the 
minor  ones  for  which  it  was  and  is  used  by  natives.  As  a  stomachic 
it  is  recognized  that  its  use  before  meals  detracts  from  the  appetite, 
but  its  use  thereafter  relieves  any  discomfort  resulting  from  excess, 
while  not  appreciably  inhibiting  digestion.  In  fact,  its  general  re- 
pute is  that  of  aiding  digestion.  The  more  important  objects  of  its 
use  is  as  a  limited  cerebral  stimulant,  an  anesthetic,  a  very  peculiar 
muscular  stimulant,  and  an  ordinary  masticatory.  As  a  cerebral 
stimulant  it  filled  the  place  of  coffee.  It  was  used  before  the  latter 
was  introduced,  and  after  that  event  it  continued  to  be  used  by  the 
natives,  while  the  much  more  expensive  coffee  was  used  by  the  for- 
eign element  In  this  direction  its  characteristics  were  to  promote 
cheerful  and  hopeful  views  and  sentiments,  without  excitability,  but 
rather  with  increased  calm.  As  an  anesthetic  its  use  was  a  general 
more  than  a  local  one,  though  it  was  locally  applied  to  ease  pain,  and 
its  carminative  and  stomachic  uses  were  clearly  of  this  nature. 

"  The  object  of  overcoming  the  pains  of  hunger  and  fatigue  was 
preeminent.  Securing  relief  from  pain  by  a  mild  anesthetic  was  in 
general  use  even  though  the  result  was  increased  wakefulness. 

"The  term  'muscular  stimulant'  is  not  accurate,  but  is  used  for 
want  of  a  better.  The  plant  was  used  to  enable  man  to  perform 
more  labor  with  less  fatigue  and  with  less  nutrition.  Without  regard 
to  the  facts  of  the  case,  this  was  the  belief  of  its  users.  In  conse- 
quence of  these  effects,  bodily  or  mental,  those  using  the  plant  per- 
formed almost  incredible  physical  tasks,  long-continued,  upon  a  food 
supply  the  scantiness  of  which  is  astonishing,  and  with  results  not 
injurious  beyond  causing  temporary  inconvenience. 

"The  special  adverse  conditions  to  be  met  with  in  these  efforts 
were  the  continued  scaling  of  steep  and  high  acclivities,  with  little 
food  and  with  a  very  scanty  supply  of  oxygen,  and  under  the  neces- 
sity of  either  attaining  a  high  speed  or  transporting  heavy  loads. 

"The  above  statements,  in  substance,  were  among  the  earliest 
historic  records  concerning  its  use  by  the  people  of  the  countries 
concerned,  and  they  have  been  repeated,  with  assurance,  by  all  sub- 
sequent investigating  travelers. 

"Many  of  these  travelers  went  to  extraordinary  lengths  to  test 
their  accuracy,  and  always  with  affirmative  results. 

"Travelers  and  foreign  residents  verified  them  by  personal  ex- 
perience and  very  frequently  relied  upon  them  for  personal  help. 
These  assertions  were  met  abroad  by  religious  opposition  because  of 
the  heathen  relations  of  the  coca  customs;  by  great  professional 


24  LOCAL   ANESTHESIA 

conservatism;  and,  by  discredit,  because  the  leaves  exported  for  use 
largely  failed,  in  the  condition  in  which  they  were  received,  to  verify 
these  assertions.  All  the  present  importance  of  the  drug  in  its  own 
form,  or  that  of  cocain,  cannot  be  said  to  cover  the  same  ground 
involved  by  the  native  uses  of  coca  leaves. 

"There  appears  to  be  but  one  rational  explanation  of  this  broad 
discrepancy,  namely,  change  in  properties  which  the  leaves  undergo 
after  being  dried.  This  view  has  been  verified  by  the  writer  by  num- 
erous assays  of  the  leaves  soon  after  collection  compared  with  others 
made  later. 

"Preparations  made  upon  the  spot  have  also  been  found,  by  ex- 
tended trial,  to  act  more  like  the  leaves  as  chewed  by  the  natives 
than  like  preparations  made  from  the  exported  leaves. 

"The  details  of  the  methods  of  use  have  been  so  often  published 
that  any  account  of  them  appears  scarcely  necessary  in  this  article. 

"The  use  of  Llipta,  or  ashes  with  the  bolus,  is  to  be  regarded 
partly  like  that  of  condiments.  Holmes  makes  the  suggestion  that 
the  effect  of  this  alkali  is  to  decompose  the  alkaloid,  cocain,  develop- 
ing new  constituents  which  exert  the  desired  physiologic  action. 
This  gives  us  food  for  experiment." 

The  earliest  record  I  can  find  of  the  use  of  any  coca  preparations 
for  their  anesthetic  effects  is  a  letter  published  in  the  New  York 
Med.  Jour.,  October  24,  1885,  by  Dr.  W.  O.  Moore,  of  New  York, 
who  states  that  for  the  past  ten  years  Dr.  Fauvel  (address  not  given) 
had  been  using  the  fluidextract  of  coca  applied  to  the  pharynx  and 
larynx  by  a  brush  or  a  spray  as  a  local  anesthetic  of  these  parts. 

Few  agents  have  sprung  so  rapidly  into  such  general  use,  and  in 
so  short  a  time  after  their  introduction  been  so  universally  tried 
in  all  departments  of  medicine.  Being  a  practically  new  departure 
in  therapeutics,  medical  and  surgical,  it  was  taken  up  by  specialists 
in  all  lines,  and  was  the  first  step  in  the  introduction  of  agents  which 
were  to  fill  a  long-felt  want.  The  literature  of  the  first  year  or  two 
following  its  introduction  is  teeming  with  articles  on  its  use,  covering 
a  wide  range  of  subjects. 

As  early  as  the  last  half  of  1885  the  New  York  Medical  Journal 
contained  twenty-eight  separate  articles  and  several  editorials  on  its 
uses ;  articles  in  other  journals  were  equally  as  numerous.  It  was,  as 
would  be  expected,  already  claiming  its  mortality  from  injudicious 
use  and  the  cocain  habit  was  even  then  reported. 

Some  of  the  interesting  papers,  even  at  this  early  time,  taken 
from  the  above-mentioned  list,  are  "Cocain  Anesthesia  in  Supra- 


HISTORY  25 

condyloid  Osteoma  and  Excision  of  the  Hip- joint"  (by  Roberts); 
"Cocain  as  A  Remedy  in  Seasickness;  As  an  Anesthetic  in  Fractures 
and  Dislocations;  In  Hay  Fever,  Opium  Addiction,  Sore  Nipples, 
Vaginismus,  Whooping-cough;  As  A  Means  of  Isolation  of  the  Tem- 
perature Sense  in  the  Oropharyngeal  and  Nasal  Cavity."  In  the 
treatment  of  facial  neuralgia,  gynecology,  labor,  nervous  affections, 
and  in  the  eye  and  ears,  as  well  as  numerous  cases  of  minor  surgery, 
it  would  be  difficult  to-day  to  conceive  of  a  more  extended  use  of  the 
drug;  we-  have  improved  the  technic  and  manner  of  its  use,  but 
certainly  have  not  extended  the  field. 

While  the  history  of  the  use  of  local  means  of  analgesia  precedes 
that  of  the  use  of  general  anesthesia,  yet  the  practical  use  of  general 
anesthesia  preceded  by  many  years  that  of  local  (chloroform,  1831; 
ether,  1842;  cocain  1884),  and  its  administration  had  reached  a  high 
degree  of  development  before  local  anesthesia  was  discovered.  Had 
this  not  been  the  case  but  the  position  reversed  and  local  anesthesia 
discovered  first,  general  anesthesia  might  now  be  struggling  to  dis- 
place it  from  its  coveted  pedestal,  and  it  is  not  to  be  doubted  but 
that  local  anesthesia  would  have  reached  a  much  higher  plane  of 
development  for  in  all  operations  suited  to  its  use  general  anesthesia 
cannot  compare  with  it  in  safety  and  comfort.  The  survival  or 
failure  of  any  method  advocated  for  practical  daily  use  must  rest 
entirely  upon  the  clinical  results  obtained.  The  prime  object  of  all 
surgery,  as  well  as  all  medicine,  is  the  relief  of  suffering  and  the  pro- 
longation of  life;  those  measures  which  attain  these  ends  with  the 
least  disturbance  to  the  patient  and  the  least  suffering  must  ulti- 
mately prevail  to  the  exclusion  of  all  other  harsher  and  less  agreeable 
methods. 


CHAPTER  II 
NERVES  AND  THEIR  SENSATIONS— ESPECIALLY  PAIN 

IN  the  practical  part  of  this  discussion  we  are  interested  only  in 
the  afferent  nerves,  particularly  those  that  transmit  painful  impres- 
sions— the  sensory  nerves.  The  subject  of  pain  and  nerve  sensations 
is  of  tremendous  interest  to  the  physician  as  well  as  to  the  surgeon, 
as  it  is  this  one  subjective  symptom  which  brings  us  most  of  our 
patients,  and  which  in  its  protean  and  manifold  manifestations  we 
are  daily  striving  to  relieve. 

No  other  phenomena  connected  with  the  life-history  of  the  human 
race  has  been  so  great  a  factor  in  the  historic  development  of  medi- 
cine as  pain.  It  can  readily  be  conceived  that  the  first  medical 
thought  and  first  effort  on  the  part  of  primitive  man  was  directed  to 
the  relief  of  pain.  And  yet,  though  it  is  the  most  universal  symptom 
of  disease,  it  is  the  least  understood,  as  there  has  been  no  adequate 
or  entirely  satisfactory  explanation  of  its  nature  and  mode  of  action. 
It  would,  therefore,  not  seem  out  of  place,  particularly  in  a  discussion 
of  this  kind,  to  deal  more  liberally  with  the  subject  and  attempt  to 
advance  some  theory  as  to  what  is  pain.  We  must  admit  that  we 
know  less  about  the  nervous  system  than  about  any  of  the  other  great 
systems  of  the  human  body,  and  the  function  of  many  parts  of  the 
brain  is  as  great  a  mystery  to-day  as  it  was  to  our  medical  forefathers. 
We  know  absolutely  nothing  about  the  metabolism  of  the  nervous 
system,  but  certain  anatomic  and  functional  facts  have  been  es- 
tablished upon  which  various  theories  have  been  built,  and  it  is  from 
this  information  that  we  will  draw  in  the  present  discussion,  consider- 
ing first  such  anatomic  and  physiologic  points  as  should  be  borne  in 
mind. 

To  many,  most  of  these  facts  are  an  old  familiar  story,  and  their 
repetition  would  scarcely  be  excusable,  and  may  be  regarded  as  a 
superfluous  waste  of  time,  were  it  not  necessary  to  consider  them 
for  a  proper  conception  of  the  theories  to  be  later  advanced. 

The  sensory  nerves  have  their  sensory  organs  at  their  peripheral 
termination.  These  are  of  several  kinds — touch  corpuscles,  end 
bulbs,  touch  cells,  and  free  nerve-endings — most  of  which  are  dis- 
tributed to  the  peripheral  tissues,  cutaneous,  mucous,  etc.  In  addi- 

26 


NERVES  AND  THEIR  SENSATIONS — ESPECIALLY  PAIN  27 

tion  to  the  above,  there  are  the  Pacinian  corpuscles,  distributed  in  the 
subcutaneous  parts,  usually  lying  in  cellular  tissue,  at  times  deeply 
situated  between  muscle  bundles;  their  function  is  not  clearly  under- 
stood, but  they  seem  to  be  connected  with  the  sensory  apparatus, 
probably  with  the  pressure  sense. 

In  addition  to  these,  we  have  the  nerves  of  special  sense,  which 
are  sensory  nerves,  only  highly  specialized  in  their  function.  Aside 
from  nerves  of  special  sense,  the  various  qualities  ascribed  to  these 
nerves  are:  (i)  pain;  (2)  tactility,  or  common  sensation;  (3)  locality; 
(4)  pressure  sense,  and  (5)  temperature  sense.  While  in  all  opera- 
tions under  local  anesthesia  we  are  concerned  more  especially  at  the 
time  with  the  pain-conducting  function  of  the  nerve,  we  must  not 
lose  sight  of  the  fact  that  most  cutaneous  nerves  are  trophic  as  well, 
and  the  deeper  nerves  contain,  in  addition,  motor  fibers.  The  opera- 
tor, under  local  anesthesia,  becomes  especially  a  nerve  anatomist, 
learning  to  search  out,  inject,  and  protect  each  individual  nerve,  and 
does  not  needlessly  divide  them,  thus  saving  its  sensory  as  well  as 
its  motor  and  trophic  function. 

We  have  said  that  sensory  nerves  have  their  sensory  organs  at 
their  peripheral  terminations,  and  we  say  that  it  is  the  brain  that  feels, 
but  the  brain  is  absolutely  devoid  of  painful  sensations;  the  exposed 
brain  of  a  thoroughly  conscious  patient  can  be  operated  upon  with- 
out any  sensations  whatever  of  pain;  stimulation  of  various  parts  of 
the  brain  may  give  rise  to  other  sensations,  but  never  pain. 

The  nerves  themselves  have  very  little  sensation,  but  refer 
any  stimulation  or  irritation  applied  to  them  to  their  periphreral 
distribution. 

What  is  pain?  Is  it  a  special  sense  of  these  afferent  nerves,  or  is 
it  an  exaggeration  of  common  sensation,  a  quantitative  increase  of 
sensibility?  If  pain  were  a  special  sense  and  traveled  along  definite 
nerve  paths  there  ought,  logically,  to  exist  a  pain  center ;  for  all  special 
senses  possess  a  special  center,  and  the  same  may  be  said  of  the  other 
cutaneous  senses.  All  of  our  numerous  experiments  and  many  clin- 
ical observations  have  failed  to  locate  such  centers. 

The  destruction  in  animals  of  the  gyrus  fornicatus,  or  the  hippo- 
campal  region,  is  said  to  be  followed  by  more  or  less  loss  of  common 
or  tactile  sensation,  and  the  entire  destruction  of  these  regions  on 
one  side  of  the  brain  is  followed  by  protracted  hemianesthesia. 

There  is,  however,  no  pathologic  evidence  to  make  the  conclusions 
drawn  from  these  experiments  applicable  to  man,  and  the  anatomic 
distribution  of  the  sensory  fibers,  as  their  path  turns  outward  from 


28  LOCAL   ANESTHESIA 

the  internal  capsule,  seems  to  prove  that  there  is  no  such  center.  It 
is,  indeed,  a  wonderful  thing  that  the  most  highly  organized  and  com- 
plex structure  within  the  human  body  should  be  entirely  devoid  of 
painful  impressions. 

Although  we  are  most  familiar  with  the  sensibility  of  the  skin, 
and  believe  that  we  perfectly  understand  the  nature  of  the  impres- 
sions upon  it,  and  the  mode  of  conveyance  to  the  sensorium,  yet 
there  is  a  difficulty  in  comprehending  the  operation  of  all  the  organs 
of  the  senses — a  difficulty  not  removed  by  the  apparent  simplicity 
of  the  sense  of  touch. 

But,  although  the  impression  be  thus  traced  to  the  extremity  of 
the  nerve,  still  we  comprehend  nothing  of  the  nature  of  that  impres- 
sion or  of  the  manner  in  which  it  is  transmitted  to  the  sensorium. 
To  the  most  minute  examination  the  nerves  in  all  their  course,  and 
when  they  are  expanded  into  the  external  organs  of  sense,  seem  the 
same  in  substance  and  in  structure.  The  disturbance  of  the  ex- 
tremity of  the  nerve,  the  vibrations  upon  it,  or  the  images  painted 
upon  its  surface,  cannot  be  transmitted  to  the  brain  according  to  any 
physical  laws  with  which  we  are  acquainted.  Experiments  prove 
what  is  suggested  by  anatomy,  that  not  only  the  organs  are  appro- 
priated to  particular  classes  of  sensation,  but  that  the  nerves  inter- 
mediate between  the -brain  and  the  outward  organs  are  respectively 
capable  of  receiving  no  other  sensations  but  such  as  are  adapted  to 
their  particular  organ.  Any  impression  on  the  nerve  of  the  eye,  the 
ear,  or  on  the  nerve  of  smell  or  of  taste,  excite  only  ideas  of  vision, 
sound,  or  smell,  etc.  No  education  or  amount  of  exercise  will  enable 
one  nerve  to  replace  the  other.  We  cannot  comprehend  anything 
of  the  manner  in  which  nerves  are  affected ;  certainly  we  know  noth- 
ing of  the  manner  in  which  sensation  is  propagated  or  the  mind  ulti- 
mately influenced. 

The  manner  of  determining  the  relative  sensibility  of  different 
nerves  by  comparison  or  a  study  of  the  many  different  causes  affect- 
ing sensibility  is,  at  times,  made  extremely  difficult.  The  observer 
must  depend  entirely  upon  the  statements  of  the  individual  experi- 
mented upon  for  his  information;  and  in  animals,  as  can  be  well 
understood,  the  difficulties  and  possibilities  of  error  are  greater. 

The  senses  are  not  equally  developed  in  all  individuals,  and  are 
differently  developed  in  man  and  animals,  according  to  their  differ- 
ent needs.  We  find  every  organ  of  sense,  with  the  exception  of  that 
of  touch,  more  highly  developed  in  the  brute  than  in  man.  In  the 
eagle  and  the  hawk,  in  the  gazelle  and  the  feline  tribe,  the  perfection 


NERVES  AND  THEIR  SENSATIONS — ESPECIALLY  PAIN  2Q 

of  the  sense  of  sight  is  admirable;  in  the  dog,  wolf,  hyena,  and 
most  animals  and  birds  of  prey  the  sense  of  smell  is  uncommonly 
acute. 

The  term  "anesthesia"  denotes  the  loss  of  tactility  and  in  its 
broad  acceptation  of  all  other  sensations  as  well;  "analgesia"  means 
the  loss  of  the  sense  of  pain  alone;  "thermo-anesthesia,"  the  loss  of 
temperature  sense. 

Some  individuals  are  affected  peculiarly  by  what  should  be  pain- 
ful stimuli,  and  do  not  complain  of  pain  as  the  most  trying  symptom; 
thus,  it  is  related  that  in  the  pre-anesthetic  days  a  French  surgeon 
was  amputating  a  limb,  and,  noticing  an  expression  of  great  distress 
upon  the  patient's  face,  said,  "I  fear  that  I  am  causing  you  great 
pain."  The  reply  was,  "No;  the  pain  is  nothing,  but  the  noise  of 
the  saw  sets  my  teeth  on  edge." 

We  find  it  equally  difficult  to  give  a  satisfactory  definition  for 
pain.  It  may,  however,  be  regarded  as  a  peculiar  discomfort  or 
suffering  caused  by  disturbances  of  the  sensory  nerves  or  nerve-cells, 
which  induce  a  condition  of  overstimulation;  thus,  any  of  our  sensa- 
tions may  become  painful  if  the  stimulus  is  sufficiently  strong  or 
prolonged.  This  will  be  illustrated  later. 

From  a  restricted  philosophic  point  of  view  pain  may  be  con- 
sidered as  a  reaction  of  the  organism,  in  part  or  in  whole,  to  harmful 
influences.  This  latter  is  more  in  accord  with  the  views  of  the  biolo- 
gists who  see  in  the  contractions  and  expansions  occurring  in  minute 
protoplasmic  life  an  expression,  in  a  primordial  way,  of  the  senses  of 
pleasure  and  pain,  expanding  in  response  to  pleasurable,  healthful 
influences,  and  contracting  in  reaction  to  painful  or  harmful  stimuli. 
These  reactions  are  considered  the  germ  of  the  idea  which,  by  many 
multiplications,  complications,  and  added  phenomena,  have  come  to 
make  the  many-sided,  complex  figure  of  the  human  pleasure-pain 
sense. 

There  may  be  many  kinds  of  pain,  and  no  less  real  than  those 
pains  due  to  the  injury  of  a  sensory  nerve.  We  may  have  pain  in 
consciousness  connected  with  the  more  complex  processes,  such  as 
fear,  anxiety,  anger,  or  the  pain  of  sorrow  or  a  "broken  heart,"  and 
other  conditions. 

If  pain  is  to  be  regarded  as  a  reaction,  there  must  be  at  least  two 
factors  involved  in  its  production:  first,  the  susceptibility  of  the  in- 
dividual; and,  second,  the  character  or  intensity  of  the  stimuli  or 
inducing  agency. 

Pain  may  be  to  many  but  an  incident  of  little  concern,  they  are 


30  LOCAL   ANESTHESIA 

either  anesthetic  or  stoical,  feeling  very  little  or  able  to  control  their 
expressions  of  pain;  others  are  hyperesthetic  or  exaggerational,  either 
being  extremely  susceptible  or  they  possess  little  or  no  control  over 
their  feelings.  These  differences  are  largely  individual,  although 
there  exists  certain  factors  in  the  race,  age,  social,  and  educational 
status  of  the  individual  which  influence  this  susceptibility;  thus,  it  is 
stated  that  the  dark  skinned  races,  and  Slavs  and  Teutons,  are  less 
susceptible  to  pain  than  other  races,  while  the  Latin  and  Semitic 
stock  are  most  susceptible.  Old  age  generally  is  less  susceptible  than 
youth  or  adolescence,  due  to  the  more  sluggish  condition  of  the 
nervous  system,  while  infancy,  due  to  the  absence  of  the  psychic  in- 
fluence and  poor  sense  of  locality,  may  bear  certain  pain  well,  but 
is  easily  shocked  by  severe  trauma. 

The  social  condition,  refinement,  and  educational  status  and  oc- 
cupation have  much  to  do  with  the  susceptibility  to  painful  impres- 
sions, as  we  would  naturally  suppose;  thus,  a  highly  refined  individual, 
following  an  intellectual  pursuit,  would  be  expected,  from  his  mode 
of  life,  breeding,  and  occupation,  to  have  a  more  highly  developed 
and  sensitive  nervous  system  than  the  laborer  or  farm  hand,  accus- 
tomed to  exposure  with  the  knocks  and  buffets  of  a  hard  life.  Sensi- 
tiveness to  pain  varies  with  individuals.  A  person  with  a  strong  will 
may  suffer  great  pain  without  flinching,  while  a  mere  trifle  may  cause 
great  complaint  from  another.  Those  of  thin  build  and  neurotic 
temperament  suffer  more  than  the  hardy  and  stout.  Carlyle  said 
"with  stupidity  and  a  sound  digestion,  man  may  confront  much." 
Carlyle  himself  was  a  neurotic.  Individuals  with  heightened  reflexes 
as  lively  knee-jerks,  the  very  ticklish  and  those  who  are  easily  startled 
and  highly  nervous  bear  pain  badly,  while  those  not  so  responsive 
make  less  complaint;  this  establishes  an  association  between  reflex 
activity  and  sensitiveness  to  pain.  To  prove  the  existence  of  pain, 
besides  the  facial  expression,  complaints  and  bodily  movements,  the 
circulation  should  be  observed.  Great  pain  almost  always  causes 
a  decided  rise  in  blood-pressure  and  when  this  does  not  occur,  doubt 
may  be  felt  regarding  the  existence,  at  least  of  severe  pain.  Cush- 
man  and  Cabot  corroborate  this  statement.  Cushman  found  that 
in  90  per  cent,  of  those  examined  with  normal  sensibility  when  stimu- 
lated with  a  strong  faradic  current  on  the  thigh,  the  blood-pressure 
rose  10  mm.  of  mercury,  the  remaining  15  per  cent,  showed  a  rise 
of  1 5°.  During  severe  attacks  of  pain  as  in  gall-stone  and  renal  colic, 
crises  of  tabes,  lead  colic  and  labor,  the  blood-pressure  may  rise  60° 
to  70°  and  80°.  The  inability  to  bear  pain  on  the  part  of  certain 


NERVES  AND  THEIR  SENSATIONS ESPECIALLY   PAIN  31 

high-strung  individuals  of  nervous  temperament  must  not  be  as- 
cribed always  to  cowardice,  for  such  persons  often  bear  themselves 
with  great  fortitude  and  heroism  when  exposed  to  grave  danger;  this 
has  often  been  noticed  in  military  officers  who  have  always  shown 
great  bravery  on  the  battlefield,  but  who  would  complain  bitterly 
when  pain  was  inflicted  during  some  minor  attention. 

In  this  last  class  of  cases  the  psychic  state  of  the  individual  plays 
a  large  part.  Of  this  factor  we  shall  have  more  to  say  later. 

Any  of  our  sensations  may  become  painful  if  the  stimulus  is  suffi- 
ciently strong  or  prolonged;  the  skin  touched  lightly  affords  normal 
tactile  sensations,  but  if  the  pressure  is  severe,  a  general  impression 
approaching  that  of  pain  is  produced. 

The  same  may  be  said  of  thermic  sensations;  while  the  power  of 
the  skin  to  recognize  differences  in  temperature  is  very  acute,  the 
ability  to  judge  the  absolute  degree  of  temperature  is  very  slight. 
When  the  degree  of  temperature  is  raised  or  lowered  beyond  a  certain 
point  the  thermic  sense  is  no  longer  excited,  but  sensations  of  pain 
are  produced.  If  we  put  our  hand  inot  freezing  or  very  hot  water,  it 
is  difficult  to  say  at  once  whether  it  is  hot  or  cold,  in  either  case  pain 
being  the  only  sensation  produced.  The  time  for  the  arrival  of  tem- 
perature impressions  at  the  brain  is  remarkably  long  when  compared 
with  the  rate  at  which  tactile  impressions  travel.  That  there  must 
be  special  nerve-endings  for  the  reception  of  thermic  impressions 
would  seem  proved  by  the  following  facts :  When  heat  or  cold  is  ap- 
plied to  a  nerve-trunk  it  does  not  give  rise  to  these  sensations;  if  a  hot 
or  cold  object  is  moved  slowly  over  the  surface  of  the  skin  some  parts 
feel  no  temperature  change,  some  feel  increased  heat,  and  others  only 
cold.  These  "hot"  and  "cold"  perception  areas  are  said  to  possess 
different  kinds  of  nerve  terminals.  It  would  seem  that  these  nerve- 
endings  are  different  from  those  which  receive  tactile  and  pressure 
impressions,  because  the  appreciation  of  differences  of  temperature 
is  very  delicately  developed  in  certain  areas  where  tactile  sensation 
is  not  acute.  Thus,  the  cheeks  and  the  eyelids  are  very  sensitive  to 
heat,  while  sensation  is  not  acute  here;  the  middle  of  the  chest  is 
also  very  sensitive  to  heat,  but  very  dull  to  tactile  impressions. 

That  all  the  different  sensations  of  the  skin  possess  different 
nerve-endings  or  paths  for  their  transmissions  is  again  argued  in  the 
difference  between  the  senses  of  locality  and  pressure,  as  the  pressure 
sense  is  found  to  be  not  so  keenly  developed  in  parts  where  the  sense 
of  locality  is  most  acute.  This  sense  of  pressure  may  be  more  ac- 
curately determined  by  the  skin  of  the  forearm  than  by  that  of  the 


32  LOCAL   ANESTHESIA 

finger-tip,  although  the  latter  is  nine  times  more  sensitive  to  ordinary 
tactile  impressions. 

Any  of  these  sensations,  with  the  exception  of  that  of  locality, 
may  become  painful  if  increased  beyond  a  certain  point.  The  same 
may  be  said,  in  a  modified  way,  of  the  exercise  of  the  functions  of 
special  sense.  Moderate  light  does  not  prove  of  discomfort  to  the 
normal  eye,  but  if  intense  the  pain  may  be  severe.  It,  however,  has 
been  observed  that  in  cases  of  total  blindness  due  to  atrophy  of  the 
optic  nerve  very  intense  light  may  produce  pain.  It  is  probable 
then,  not  the  optic  nerve,  or  it  alone,  which  feels  the  pain  of  over- 
stimulation,  but  the  trigeminus.  Sounds,  such  as  music,  cause  pleas- 
ure when  conveyed  to  the  brain  over  the  auditory  nerve,  but  if  it 
were  possible  that  these  pleasurable  sounds  could  be  magnified  to  a 
high  degree  they  would  undoubtedly  become  painful,  but  here,  as  in 
the  case  of  the  other  noises  which  set  up  violent  sound-waves,  it  is 
probable  not  the  auditory  nerve,  or  it  alone,  as  in  the  case  of  the  eye, 
which  feels  the  pain,  as  it  is  most  likely  due  to  mechanical  injury 
to  the  tympanum  and  ossicles  supplied  by  the  fifth  nerve.  Certain 
tastes  or  odors,  when  of  moderate  intensity,  are  pleasant,  but  may 
become  decidedly  disagreeable,  or  provoke  other  unpleasant  sensa- 
tions when  markedly  increased.  But  here  these  special  end-organs 
seem  to  have  a  chemical  function,  while  the  excitation  of  nerves 
generally  is  rather  of  a  mechanical  nature. 

It  will  now  not  be  out  of  place  to  consider  certain  other  facts  in 
connection  with  pain  and  sensations  generally.  Pain  may  be  caused 
by  mechanical,  thermal,  chemical,  electric,  or  other  means. 

The  duration  and  extent  of  a  stimulation  may  determine  in  great 
measure  the  sensations  produced,  as  illustrated  by  the  contact  of  a 
hot  surface  for  a  short  or  long  time,  or  by  picking  the  skin  lightly 
with  one  pin  or  with  a  number  at  the  same  time. 

.  There  are  some  facts  which  seem  to  point  to  the  conclusion  that 
pain  has  a  functional  independence,  whatever  may  be  said  regarding 
its  anatomic  independence.  Whether  there  are  or  are  not  special 
nerve  fibers  which  conduct  pain  is  a  subject  on  which  laboratory  ex- 
periments are  in  doubt.  As  an  illustration,  pain  may  be  abolished 
without  destroying  or  impairing  any  of  the  other  sensibilities  as  is 
seen  in  analgesia,  brought  on  by  the  administration  of  a  general  anes- 
thetic. Observations  prove  the  fact  that  pain  disappears  first,  then 
memory. 

On  the  other  hand,  other  sensations  may  be  destroyed  while 
pain  remains.  When  a  part  of  the  body  (an  extremity)  is  rendered 


NERVES   AND   THEIR   SENSATIONS ESPECIALLY  PAIN  33 

anemic,  tactility  disappears  first,  followed  by  pain,  then  the  thermic 
sense. 

Pain  rarely  ever  remains  constant  in  the  same  degree,  but  inter- 
mits, while  the  stimulus  may  remain  constant.  This  intermittance 
may  take  the  nature  of  a  throb  as  in  headache,  jumps  as  in  tooth- 
ache, or  as  in  bone- felons,  in  which  the  paroxysms  become  overpower- 
ing. These  intermissions  in  some  cases  are  no  doubt  synchronous 
with  the  pulse,  or  due  to  other  reactions  in  the  vascular  system, 
bringing  about  distention  or  vascular  contractions.  Other  influences 
also  determine  the  onset  of  the  paroxysms  or  increases  of  intensity 
as  seen  in  neuralgias. 

Certain  other  phenomena  are  the  delays  noticed  in  recording  a 
painful  impressions  following  a  blow.  The  shock  from  the  blow  is 
often  felt  an  appreciable  interval  of  time  before  the  pain  is  felt;  this 
may  or  may  not  be  due  to  the  shock  having  paralyzed,  for  a  moment, 
the  sensory  nerve-endings  or  their  power  of  transmission.  But  this 
would  hardly  seem  the  case  in  injuries  of  moderate  severity  which  yet 
cause  pain. 

While  we  know  that  tactile  impressions  travel  at  the  rate  of  42 
meters  per  second,  and  painful  impressions  only  at  the  rate  of  10 
meters  per  second,  still  the  delay  is  much  greater  than  would  be 
accounted  for  by  this  difference. 

Again,  the  lasting  quality  of  a  painful  impression  is  sometimes 
remarkable.  Pains  do  not  always  pass  away  when  the  stimulation 
ceases,  but  may  remain  for  some  time  as  an  after-image.  This  is 
probably  due  to  the  fact  that  the  intense  stimulation  necessary  for 
the  production  of  pain  produce  a  more  decided  and  lasting  character 
in  the  nervous  changes  than  other  sensations  do.  The  demonstrated 
fact  that  there  exists  definite  pain-points,  cold-points,  heat-points, 
and  pressure-points  in  the  skin  would  argue  for  the  distinction  and 
independence  of  each  of  these  sensations. 

The  sensory  apparatus,  once  excited,  does  not  immediately  sub- 
side into  a  non-active  state,  but  the  pulse  or  wave  of  molecular  change 
which  has  been  set  up  in  the  nerve  centers  remains  for  a  longer  or 
shorter  time.  To  better  understand  this  phenomenon,  we  can  take 
for  an  illustration  the  optical  delusion  produced  by  a  very  rapidly 
revolving  torch  which  appears  as  a  circle  of  fire,  because  the  impres- 
sion created  by  the  torch  at  any  one  point  of  the  circle  does  not  dis- 
appear before  it  has  again  reached  the  same  point;  or  the  same  may 
be  illustrated  in  the  revolving  spokes  of  a  wheel. 

A  contrast  noticed  in  the  apparent  absence  of  pain  when  the  in- 


34  LOCAL   ANESTHESIA 

tensity  of  a  painful  stimulus  is  suddenly  lessened,  even  though  the 
lessened  intensity  would  be  painful  under  other  conditions,  is  ex- 
plained in  the  above  way. 

Practically,  all  physiologists  agree  that  we  cannot  feel  two  en- 
tirely different  sensations  at  the  same  time.  One  must  be  paramount 
and  the  other  subordinate,  or  each  impression  will  be  diminished,  so 
that  their  united  influence  would  only  equal  what  either  would  be 
alone.  And  the  same  is  true  of  painful  sensations:  a  man  with  both 
legs  broken  feels  pain  in  but  one  at  a  time.  The  same  thing  takes 
place  continually  with  reference  to  all  of  our  sensations,  whether  of 
pleasure  or  pain;  we  are  only  conscious  of  what  may  be  the  paramount 
influence.  This  fact  explains  in  a  great  measure  the  psychic  control 
over  pain.  With  the  mind  and  attention  occupied  by  some  all-ab- 
sorbing and  engrossing  subject,  great  enough  to  hold  the  attention, 
pain  is  not  felt,  as  illustrated  elsewhere  in  this  discussion. 

Another  important  consideration  in  the  exercise  of  our  sensations 
is  the  necessity  for  a  change  of  stimuli!  Any  sensation,  whether 
pleasurable  or  otherwise,  if  too  long  continued  becomes  weakened  or 
exhausted  It  is  only  by  constant  change,  contrast,  and  comparison 
that  we  continue  to  exercise  our  many  senses,  but  no  two  of  them  at 
the  same  time.  We  can  illustrate  this  by  pleasurable  sensations,  we 
will  say  at  the  theater,  where  the  senses  of  sight  and  hearing  are  both 
exercised,  but  alternately,  the  change  enhancing  and  increasing  the 
pleasure  derived  from  the  exercise  of  the  other.  Music  to  the  blind 
is  not  so  pleasing  as  to  the  more  fortunate  who  can  see,  and  the  deaf 
derive  less  pleasure  from  the  sense  of  sight  alone,  although  in  either 
case  it  may  be  the  only  amusement  or  distraction  which  they  have. 
Cold  and  heat  are  distinct  sensations,  and  this  is  so  far  important 
that  without  such  contrast  we  should  not  continue  to  enjoy  the  sense, 
for  the  variety  of  contrast  is  absolutely  necessary  to  sensation.  The 
hand  placed  in  moderately  hot  water  soon  becomes  accustomed  to  it, 
and  we  no  longer  feel  the  sensation,  or  less  so,  and  the  same  with  cold. 
The  first  shock  is  the  greatest,  and  the  hand  alternately  plunged  from 
moderately  hot  into  cold  water  feels  the  contrast  more  keenly  as  the 
sense  is  excited  by  the  change.  It  is  by  a  comparison  of  cold  and 
heat  that  we  enjoy  either  sensation.  All  senses  are  exhausted  by  ex- 
ercise without  change,  but  some  are  more  lasting  than  others.  We 
note  the  relish  with  which  one  enjoys  cool  air  after  a  long  and  ex- 
hausting high  temperature,  or  the  comfort  experienced  by  a  warm 
fire  during  the  midst  of  a  cold  winter. 

If  we  take,  for  example,  vision,  and  gaze  fixedly  at  a  single 


NERVES  AND  THEIR  SENSATIONS — ESPECIALLY  PAIN  35 

color  or  a  single  object,  the  sense  is  soon  exhausted  until  we  see 
nothing. 

The  psychic  control  over  pain  is  very  great  indeed,  probably 
much  greater  than  even  the  medical  mind  fully  appreciates  on  casual 
thought.  This  psychic  control  over  pain,  as  well  as  over  the  other 
senses,  is  thoroughly  in  accord  with  the  recognized  physiologic  law 
that  we  cannot  be  conscious  of  two  sensations  at  the  same  time. 
With  the  mind  intently  fixed  on  the  idea  that  pain  is  to  be  inflicted 
the  suffering  is  always  more  acute,  and  vice  versa,  with  the  mind 
intently  fixed  and  absorbed  by  some  object  or  aim  in  view,  the  great- 
est mutilations  are  possible  without  complaint.  This  is  seen  in  the 
case  of  religious  devotees  and  fanatics,  who  often  inflict  the  severest 
personal  chastisement  without  apparent  pain. 

With  the  attention  fixed  on  the  idea  that  pain  is  to  be  inflicted, 
and  all  the  senses  keenly  alive  and  active,  awaiting  the  impression, 
the  least  touch  or  manipulation  may  excite  the  idea  of  pain  and  cause 
the  patient  to  cry  out.  One  feels  the  stick  of  a  pin  much  more  keenly 
when  watching  and  waiting  for  it  to  pierce  the  flesh.  On  the  other 
hand,  the  most  severe  injuries  may  often  be  inflicted  when  the  atten- 
tion is  diverted  or  the  mind  intensely  fixed  upon  other  things,  as  can 
be  illustrated  by  frequent  incidents  upon  the  battlefield,  where  arms 
have  been  shot  away  or  other  severe  injuries  inflicted  without  the 
individual  being  conscious  of  it  until  his  attention  is  drawn  to  it. 
For  instance,  we  are  unconscious  of  noises  when  our  mind  and  atten- 
tion is  firmly  fixed  upon  other  things,  and  with  our  mind  so  occupied 
we  may  even  look  at  things  without  seeing  them. 

Numerous  illustrations  could  be  given  of  the  psychic  control  over 
pain  or  its  influence  in  producing  shock.  It  is  related  that  a  French 
criminal  was  experimented  upon,  being  led  to  believe  that  he  was  to 
be  bled  to  death.  He  was  accordingly  blindfolded  and  prepared. 
His  arm  was  severely  pinched,  when  he  was  told  that  a  vein  had  been 
opened.  The  surgeons  who  were  making  the  experiment  allowed  a 
small  stream  of  warm  water  to  trickle  over  the  arm,  pretending  that 
it  was  the  escaping  blood.  One  observer  then  took  charge  of  the 
pulse,  and,  pretending  to  count  it,  reported  from  time  to  time  that 
it  was  gradually  growing  weaker  and  the  patient's  strength  failing. 
The  psychic  impression  was  too  much  for  the  man  to  resist.  He 
accordingly  grew  weaker  and  weaker,  being  influenced  by  the  sug- 
gestions of  those  about  him,  who  very  seriously  announced  every  few 
minutes  that  he  was  gradually  sinking.  This  was  carried  to  the  point 
of  producing  psychic  inhibition  of  the  heart,  resulting  in  arrest  of  its 


36  LOCAL   ANESTHESIA 

action  and  death.  Numerous  other  instances  could  be  related,  but 
one  more  will  suffice  to  illustrate  this  extreme  psychic  influence  some- 
times exercised.  A  French  soldier  (Boutibonne)  was  in  the  thick  of 
the  fight  at  Wagram.  Men  were  falling  all  around  him,  when  he 
felt  both  his  legs  carried  away  by  a  cannon-ball.  He  sank  down 
about  1 8  inches,  and  fell  back  benumbed  by  the  shock.  He  was  told 
by  those  around  him  that  if  he  remained  perfectly  quiet  it  would 
lessen  the  hemorrhage;  he  accordingly  lay  absolutely  quiet  until  the 
next  morning,  when  the  surgeons  reached  him  and  found  that  the 
cannon-ball  had  passed  through  the  ground  beneath  his  feet,  which 
sank  into  the  furrow,  but  that  he  had  been  entirely  unhurt.  (Related 
in  "Sensation  and  Pain,"  Taylor,  p.  55.) 

The  state  of  the  mind  has  much  to  do  with  the  activity  of  all 
our  senses.  By  our  own  mental  operations  we  can  deceive  ourselves 
by  delusions  of  vivid  reality,  which  at  times  can  be  controlled  only 
by  our  reason.  By  a  mental  state  of  dread,  fear,  or  hope  continu- 
ously exercised  we  can  excite  in  our  senses  sounds,  visions,  and  other 
sensations.  Shipwrecked  sailors  anxiously  waiting  and  hoping  for 
rescue,  with  their  eyes  strained  across  a  waste  of  water,  eagerly  seek- 
ing a  sail,  often  in  their  imagination  see  ships  approaching,  and  these 
delusions  occur  long  before  the  bodily  forces  are  exhausted  by  hunger 
and  thirst.  Numerous  similar  accounts  have  been  published  by 
hunters  and  travelers  lost  upon  the  prairies  or  desert,  knowing  that 
searching  parties  would  be  sent  out,  have  heard  and  seen  in  their 
anxiety  the  approach  of  galloping  horsemen  in  vivid  reality,  only  to 
have  the  sight  and  sounds  fade  away  like  a  mirage  on  the  exercise  of 
reason.  A  similar  experience  is  related  by  Taylor  in  "Sensation  and 
Pain."  In  the  early  days  of  Illinois  he  was  lost  on  a  dark  night  upon 
the  prairie.  There  was  no  danger,  only  the  discomfort  of  remaining 
out  all  night.  He  wandered  for  several  hours  trying  to  find  his  way, 
but  to  no  avail.  He  realized  that  his  absence  from  home  would  make 
his  friends  anxious  and  he  would  be  searched  for,  he  accordingly  was 
on  the  alert  for  the  sound  of  horses'  feet  and  a  voice  calling.  He 
listened  intently,  and  felt  sure  of  the  approach  of  a  galloping  horse. 
The  sound  gradually  approached  and  grew  more  and  more  distinct, 
but  finally  faded  away,  only  to  be  repeated  time  and  again.  In 
reasoning  over  the  matter  he  concluded  that  his  senses  were  deluding 
him;  he  then  turned  in  the  opposite  direction,  and,  after  listening 
intently,  he  heard  the  same  sounds  from  that  direction  and  from  any 
direction  from  which  he  listened;  he  concluded  that  he  was  deceived 
by  his  own  senses.  He  then  laid  down  to  sleep  and  next  morning 


NERVES  AND  THEIR  SENSATIONS — ESPECIALLY  PAIN  37 

found  his  way  home,  and  learned  that  no  one  had  been  searching 
for  him.  A  scared  child  or  nervous  woman  will  hear  and  see  a  thief 
in  the  room  at  night  when  none  is  there. 

Under  similar  conditions  the  senses  of  touch  and  pressure  are 
equally  and  vividly  deceptive,  and  the  same  may  be  said  of  all  our 
senses.  Hypnotism  is  simply  an  extreme  concentration  of  the 
attention. 

Very  practical  use  can  be  made  of  the  fact  that  sensations  of 
whatever  kind  are  not  only  mental,  but  depend  for  force  and  quality 
on  the  actual  present  state  of  the  mind.  Conscious  sensation, 
whether  objective  or  subjective,  is  a  mental  act.  A  sensory  impulse 
becomes  a  conscious  sensation  only  by  producing  a  display  of  energy 
in  the  cerebral  nerve  centers  or  brain  of  a  certain  or  cognizable  degree 
of  force,  and  then  only  when  the  attention  is  not  engaged  with  other 
relatively  paramount  sensations.  "Attention,  occupied  with  one 
sensation,  excludes  other  sensations  while  thus  occupied"  (Taylor). 

Having  recognized  this  psychic  influence  over  our  sensations,  we 
can  readily  understand  why  children  and  nervous  individuals  who 
are  unable  to  exercise  any  self-control  suffer  such  mental  torture 
when  about  to  undergo  some  trivial  attention,  and  why  such  sub- 
jects, when  taken  into  an  operating-room,  with  its  strange  surround- 
ings, white-capped  and  masked  operators,  to  undergo  some  operation 
under  local  anesthesia,  with  all  their  senses  keenly  alert  in  dreadful 
anticipation  of  the  impending  procedure,  magnify  so  greatly  in  their 
own  minds  their  sensations  that  tactility  is  often  interpreted  as  pain, 
the  least  touch  causing  them  to  jump  and  start  with  fright. 

"Cowards  die  many  times  before  their  deaths; 
The  valiant  never  taste  of  death  but  once." 

It  is  for  this  reason  that  the  preliminary  hypodermic  of  a  small 
dose  of  morphin,  alone  or  combined  with  scopolamin,  by  dulling 
their  sensibilities  and  mental  activities,  producing  a  somnolent,  tran- 
quil, or  inactive  state  of  mind,  thus  protecting  the  patient  against 
himself,  has  proved  so  useful  a  preliminary  or  adjunct  in  all  local 
anesthetic  procedures  upon  nervous  or  highly  apprehensive  indi- 
viduals, thus  rendering  valuable  aid  in  the  anoci-association  of  fear. 

DISTRIBUTION  OF  SENSATION 

The  skin  is  the  great  sensory  organ  of  the  body,  and  to  it  are  dis- 
tributed most  of  the  sensory  nerves,  but  the  distribution  of  these 
nerves  vary  within  certain  limits.  It  is  provided  that  the  more  a 


38  LOCAL   ANESTHESIA 

part  is  exposed,  and  in  proportion  to  its  delicacy  of  organization,  the 
more  exquisitely  contrived  and  highly  developed  is  the  apparatus  for 
its  protection,  and  the  more  peremptory  is  the  demand  for  the  ac- 
tivity of  that  mechanism,  as  in  the  case  of  the  eye  protected  by  its 
lids,  which  acts  involuntarily  for  protection  and  before  the  will 
could  set  them  in  motion;  and  the  same  with  the  hand,  which  is 
involuntarily  withdrawn  from  the  first  touch  of  danger  before  the 
will  can  act.  The  more  exposed  a  part,  the  more  highly  developed 
is  its  sensibility.  The  sensibility  of  the  back  and  buttocks  is  dull 
when  compared  to  that  of  the  face  or  hands.  Tickling  the  lip  with 
a  straw  or  feather  becomes  extremely  unpleasant,  while  on  the  back 
it  may  not  be  felt. 

Certain  senses  are  limited  almost  exclusively  to  the  skin,  as  tac- 
tility,  locality,  and  thermic  sense;  although  with  the  latter  certain 
mucous  surfaces  feel  both  heat  and  cold,  as  experienced  in  the  case  of 
hot  or  cold  drinks  too  rapidly  swallowed,  when  the  stomach  dis- 
tinctly feels  the  sensation,  or  in  the  case  of  ice-water  enemas,  given 
in  cases  of  fever,  the  bowel  feels  the  sense  of  cold. 

Subcutaneous  cellular  tissue  and  fat  have  very  little  sensation. 
In  the  subcutaneous  fat-tissue  and  other  parts  further  removed 
from  the  surface  are  encountered  the  pacinian  corpuscles,  which 
are  visible  to  the  naked  eye  as  little  globular-like  masses.  They 
are  connected  with  sensory  nerves  and  transmit  painful  impres- 
sions; what  other  function  they  possess,  if  any,  is  not  known. 

Between  the  muscle  bundles  are  numerous  small  nerves  which 
are  quite  sensitive  to  pain,  otherwise  muscle-fiber  is  almost  devoid 
of  sensation. 

The  periosteum  is  quite  sensitive,  acutely  so  in  the  inflamed  state. 
Bones  receive  nerve-fibers  from  the  overlying  periosteum,  but  when 
the  periosteum  has  been  anesthetized  or  has  been  denuded,  the  bone 
is  then  quite  insensitive.  Marrow  is  sensitive,  but  varies  greatly 
in  different  individuals.  It  receives  nerve-fibers  from  the  same 
source  as  the  bone,  and  when  these  have  been  anesthetized  or  de- 
stroyed the  marrow  is  then  insensitive.  The  same  can  be  said  of 
perichondrium  and  cartilage — the  perichondrium  is  sensitive,  but 
cartilage  not  so. 

Tendon-sheaths  are  sensitive,  but  tendons  and  aponeurosis  pos- 
sess very  little,  if  any,  sensation.  Synovial  membranes  are  quite 
sensitive.  The  mucous  membrane  of  all  the  passages  communicat- 
ing with  the  surface  are  quite  sensitive,  that  covering  the  gums  and 
hard  palate  much  less  so  than  that  of  the  surrounding  parts. 


NERVES   AND   THEIR   SENSATIONS ESPECIALLY  PAIN  39 

Some  distance  from  the  external  openings  these  parts  lose  their 
sensation.  The  mucous  membrane  of  the  esophagus  and  trachea 
are  insensitive;  the  esophagus,  however,  has  a  limited  sensibility 
for  heat. 

Vessels  (arteries  and  veins),  except  of  the  smallest  size,  are  sensi- 
tive to  pain,  and  this  even  in  parts  ordinarily  devoid  of  sensation. 
Fat  has  no  sensations,  but  the  vessels  which  course  through  fatty 
tissue  are  quite  sensitive. 

In  the  omentum,  which  has  no  painful  sensations,  the  large  ves- 
sels are  quite  sensitive  and  should  not  be  clamped,  ligated,  or  cut 
without  first  blocking  them.  The  vessels  of  the  mesentery  are  also 
quite  sensitive. 

These  latter  facts,  and  the  sensitiveness  of  the  various  cavities 
and  their  contents — cranial,  thoracic,  and  abdominal — will  be  dealt 
with  in  dealing  with  these  parts. 

All  organs  have  certain  sensations  and  respond  to  certain  im- 
pulses, nervous  and  otherwise,  although  normally  we  are  not  con- 
scious of  their  actions.  Thus,  the  heart,  while  insensible  to  touch, 
is  yet  alive  to  every  variation  in  the  circulation,  subject  to  change 
from  every  alteration  of  posture  or  exertion,  and  is  in  sympathy 
of  the  strictest  kind  with  the  constitutional  processes. 

One  of  the  most  interesting  theories  of  pain,  and  to  us  the  most 
plausible,  at  least  in  the  present  state  of  knowledge,  is  the  theory 
of  quantitative  increase  of  normal  sensation.  This  beautiful  theory 
was  admirably  presented  by  that  great  philosopher  of  medicine, 
Prof.  C.  Schleich,  in  his  own  inimitable,  yet  simple  and  effective 
style,  in  an  address  on  anesthetics  at  the  von  Bergmann  Memorial. 
The  following  quotations  are  extracts  from  this  address: 

"Is  pain  a  sensation  of  physical  discomfort  conducted  over  nerv- 
ous paths  designed  for  this  specific  impression,  or  is  this  general 
sensation  of  a  threatening  character  only  an  increase  or  abnormal 
excitation  of  the  tactile  sensation? 

"Are  these  special  nerves  of  pain  implanted  in  the  living  organ- 
isms to  receive  disturbing  impressions,  or  do  all  sensory  nerves, 
that  is,  all  ramifications  of  the  cerebrospinal  plexus,  if  abnormally 
stimulated,  become  conductors  of  exceptionally  perceptible  cerebral 
impressions?  (2)  Is  pain  only  a  quantitative  increase  of  sensibility 
or  is  it  a  psychonervous  function  of  a  special  kind? 

"If  we  accept  Darwin's  theory  of  evolution,  all  living  tissue 
must  have  been  evolved  by  adaptation  to  the  conditions  of  organic 
life.  Thus  certain  nervous  paths,  originally  only  serving  the  simplest 


40  LOCAL   ANESTHESIA 

tactile  and  reflex  functions,  might  have  evolved  themselves  by 
adaptation  and  heredity  into  carriers  of  impressions  of  discomfort. 
"This  theory  seems  to  me  to  be  amply  borne  out  by  the  observa- 
tions, first  reported  by  me  and  afterward  confirmed  by  Lennander, 
Block,  and  Braun,  that  all  nervous  paths  appertaining  to  the  vis- 
ceral system,  including  the  sympathetic  system,  that  intermediary 
brain,  as  it  has  been  called,  are  primarily  non-susceptible  to  pain- 
ful impressions,  only  after  the  surgeon  has  worked  for  some  time 
on  the  intestines,  the  walls  of  the  stomach,  or  the  uterus;  the  aston- 
ished ganglia  and  nerve  branches,  never  before  bothered  by  external 
interference,  so  to  speak,  recovering  from  their  perplexity,  become 
sensible  of  the  abnormal  lesion  and  conduct  and  thus  produce  the 
sensation  of  pain.  Does  not  the  accumulation  of  visceral  pains 
after  some  laparotomies,  with  their  sudden  attacks  of  postoperative 
colic,  speak  plainly  of  the  possibility  of  nervous  pain,  which,  in  the 
economy  of  nature,  originally  were  designed  for  entirely  different 
functions?  Thus  we  see  in  operations,  for  instance,  on  the  visceral 
peritoneum,  the  evolution  of  nerves  in  a  primarily  insensible  region 
into  conductors  of  pain,  and  the  same  process  of  evolution  has  taken 
place  on  the  external  surface  of  the  body.  The  tactile  nerves  have, 
in  the  course  of  many  thousands  of  years,  learned  to  send,  at  the 
irruption  of  external  forces,  a  quick,  incisive  warning  to  the  soul, 
saying,  'there  is  something  threatening  and  destructive.'  Hence 
pain  is  a  warner,  an  exhorter,  calling  for  defense,  for  fight,  for  the 
employment  of  all  measures  of  resistance  and  self-preservation.  But 
how  is  it  that  in  these  central  messages  a  contact,  which  is  usually 
transmitted  as  tactile,  heat  or  muscular  sensation  assume  at  once 
the  character  of  a  fiery  streak,  arousing  the  brain?  How  is  it  that 
such  a  peculiarly  eccentric  stormy  wave  rushes  over  the  special 
paths  usually  transmitting  only  local  impressions?  This  can  only 
be  explained  by  the  assumption  that  the  impression  of  pain  necessi- 
tates a  defect  in  the  transmission,  a  disturbance  in  the  current,  and 
the  isolation.  Here  comes  my  theory  of  the  inhibitory  and  isolating 
function  of  the  neurilemma  and  the  neurolgia,  which  may  be  con- 
densed in  the  sentence  that  pain  is  the  effect  of  an  electric  short 
circuit  of  the  sensory  nerve  paths.  All  nerves  are  embedded  in  an 
isolating  sheath  of  connective  tissue.  The  neurilemma  plays  the 
same  role  as  the  green  silk  thread  covering  the  copper  wire  of  our 
electric  batteries.  If  the  neurilemma  is  forcibly  broken  from  the 
outside,  or  pathologically  loosened  or  softened  from  the  inside,  there 
is  a  lateral  short  circuit  comparable  to  a  fiery  spark  into  which  all 


NERVES  AND  THEIR  SENSATIONS — ESPECIALLY  PAIN  41 

the  radiating  nerve  currents  are  discharged,  and  this  short  circuit 
causes  a  general  collective  message  of  alarm  to  be  registered  in  the 
brain,  notifying  it  of  a  defect  at  the  periphery,  differing  greatly  from 
the  usual  impressions  received  over  the  same  paths.  This  produces 
a  general  impression  of  discomfort  at  being  unable  to  quickly  localize 
the  unusual  general  message,  a  sensation  of  confusion,  with  threats 
of  destruction,  which  chaotically  rushes  through  the  different  centers 
of  perception,  and  it  is  this  sensation  which  we  conventionally  call 
pain. 

"Its  cause  is  an  organic  or  dynamic  lesion  of  the  lateral  inhibition 
or  isolation  of  the  nerve  branches.  We  must  assume  that  the  normal 
tissue  fluids  have  an  inhibitory  isolating  influence,  favorable  to  the 
nerve  currents,  and  that  pathologic  or  artificial  changes  in  the  fluids 
surrounding  and  permeating  the  neurilemma  may  as  readily  cause 
lateral  short  circuits,  as  foreign  bodies,  crystals,  or  micro-organisms 
do  which  directly  injure  the  isolations  of  the  nerve  branches.  At  this 
point  my  deductive  views  had  reached  a  promising  stage.  If  this 
theory  of  the  function  of  connective  tissue  for  the  mutual  isolation 
was  true,  then  there  must  exist  ways  and  means  to  increase  or  de- 
crease this  isolation  at  will  by  the  infiltration  of  fluids.  That  was 
simpler  than  to  investigate  why,  in  some  cases  of  edema  of  the  skin, 
the  pain  on  introducing  a  needle  is  less  than  usual  and  in  others 
stronger.  What  was  most  obviously  indicated  was  to  determine 
the  saline  contents  of  such  edematous  effusions,  which  proved  that 
the  anesthesia  of  the  swollen  skin  depended  on  an  abnormally  low 
amount  of  salt  present,  while  the  hyperesthesia  was  caused  by  un- 
usually high  percentages  of  sodium  chlorid,  and  this  observation 
was  immediately  confirmed  by  personal  experiments.  Welts  in  the 
writer's  skin,  produced  with  a  0.2  per  cent,  saline  solution,  were  anes- 
thetic, others  from  a  i  to  2  per  cent,  solution  were  painful,  while 
physiologic  solution  produced  no  disturbances  of  sensation." 

Equally  interesting  is  the  vibrating  theory  of  nerve  function, 
which  presumes  for  all  nerve  tissue  a  certain  degree  of  rapidity  of 
vibration  for  functional  activity,  and  is  thoroughly  compatible 
with  the  theory  of  a  quantitative  increase  of  stimuli  necessary  for 
the  production  of  pain.  This  vibratory  theory  deals  more  with 
the  transmission  of  pain  than  with  its  cause.  There  is  much  to  prove 
this  theory,  both  anatomically  and  physiologically.  Many  points  in 
the  structure  of  nerve-cells  is  decidedly  suggestive  that  these  cells, 
or  their  numerous  processes,  are  in  a  state  of  active  vibration  at 
least  during  functional  activity. 


42  LOCAL   ANESTHESIA 

We  know  that  all  matter  in  the  universe  is  in  constant  motion; 
nothing  is  ever  at  rest,  organic  or  inorganic.  Even  the  densest  rocks 
are  constantly  undergoing  a  molecular  readjustment.  This  rule 
applies  also  to  all  cells  which  go  to  make  up  animal  life.  Motion 
never  ceases  in  any  kind  of  matter;  in  animals  after  death  the  kind  of 
motion  may  change,  but  no  kind  of  matter  is  ever  at  rest.  It  is  this 
unceasing  motion  which  contributes  to  bring  about  the  constant 
changes  which  are  occurring  in  the  world  about  us  through  the  prog- 
ress of  time. 

Nerve  function  or  nerve  force  is  very  closely  allied  to  electricity, 
with  which  all  animal  bodies  are  charged.  Galvani  first  demon- 
strated the  electric  current  in  the  sciatic  nerve  of  the  frog.  Since 
then  it  has  become  an  accepted  fact  that  all  animal  tissue  was  cap- 
able of  producing  electric  currents,  and  that  electric  and  nerve  cur- 
rents obey  the  same  general  laws  (Helmholtz,  Humbolt,  DuBois- 
Reymond). 

Electricity  is  capable  of  exciting  the  function  of  nerves.  Applied 
to  a  motor  nerve,  muscular  contraction  takes  place;  applied  to  the 
cheek,  taste  is  excited;  over  the  forehead,  light  is  produced;  and  when 
applied  to  the  ears,  sound  is  heard. 

Humphries,  in  quoting  from  Abrams,  states:  "Artificial  electric 
stimulation  of  nerve-fibers  corresponds  most  nearly  to  their  natural 
excitation,  and  we,  therefore,  assume  in  our  present  state  of  knowl- 
edge that  nerve  force  and  electricity  are  identical." 

If  electricity  is  a  form  of  motion,  and  moves  along  wires,  and 
if  nerve  currents,  obey  the  same  general  laws  which  govern  electric 
currents,  we  are  probably  not  far  wrong  in  presuming  that  all  nerve 
function  is  a  special  kind  of  motion  which  takes  place  in  nerve  tissue. 
We  do  not  mean  the  constant  molecular  changes  which  are  con- 
stantly taking  place  in  all  tissue  and  have  to  do  with  repair  and 
growth,  but  a  special  vibratory  motion,  which  takes  place  during 
functional  activity  and  is  stilled  or  lessened  during  rest. 

If  this  be  accepted  and  nerves  (their  atoms  or  ions)  be  in  a  con- 
stant state  of  vibration,  an  alteration  or  change  in  this  vibration 
affecting  the  conductivity  or  resistance  may  make  itself  known 
to  our  consciousness  by  various  sensations.  We  know  that  many 
of  these  sensations,  which  are  known  to  our  senses  as  sound,  heat,  or 
light,  are  various  degrees  of  motion.  Sound  means  a  vibration  of 
36,000  per  second;  heat,  18,000,000  per  second;  while  462,000,000,000 
vibrations  per  second  produce  light.  Different  colors  are  due  to 


NERVES  AND   THEIR  SENSATIONS ESPECIALLY  PAIN  43 

different  rates  of  vibration.  Violet  is  the  highest  degree  of  vibra- 
tion which  we  can  appreciate,  733,000,000,000  per  second. 

Any  disturbance  which  may  bring  about  a  readjustment  of  the 
nerve  elements,  causing  an  altered  conductivity  or  resistance,  may 
produce  abnormal  sensations;  any  stimuli,  able  to  increase  these  vi- 
brations beyond  the  normal  limit,  producing  pain,  and  when  able  to 
lessen  or  alter  them  other  sensations  occur,  a  diminution  or  com- 
plete stilling  of  the  vibrations  producing  anesthesia;  thus  heat, 
which  is  motion  when  increased  beyond  a  certain  point,  causes  pain ; 
and  cold,  which  is  the  absence  of  motion,  when  lowered  to  a  certain 
degree  by  diminishing  or  stilling  motion,  produces  anesthesia.  This 
vibratory  theory  explains  why  nervous  or  neurotic  individuals,  with 
highly  active  and  impressionable  nervous  systems,  stand  pain  so 
poorly,  and  why  the  phlegmatic,  with  sluggish  and  inactive  nervous 
systems,  stand  it  comparatively  well. 

Some  observers,  accepting  this  vibrating  theory,  have  claimed 
that  pressure,  by  bringing  about  an  altered  conductivity  or  resist- 
ance, producing  an  alteration  in  the  nerve-cells  or  in  the  nerve  cur- 
rents, produced  sensations  of  pain,  and  have  claimed  that  all  pain  is 
pressure;  thus,  headache,  toothache,  burns,  inflammations,  malaria, 
etc.,  by  irritating  the  cells,  causes  them  to  swell,  and  this  increased 
pressure  causes  pain.  Stasis  is  a  form  of  pressure;  this,  however,  is 
not  always  felt  at  the  point  of  pressure,  but  may  be  referred. 

This  theory,  as  pointed  out  by  Humphries,  is  thoroughly  com- 
patible with  the  action  of  many  agents  used  to  control  pain  or  produce 
anesthesia;  thus,  general  anesthetics  paralyze  the  higher  centers, 
narcotics  numb  them  or  lessen  their  activity,  and  local  anesthetics 
paralyze  the  nerve-fibers  or  end-organs  with  which  they  come  in 
contact.  Many  agents  act  in  a  mechanical  way;  thus,  external  heat 
or  cold,  a  mustard  poultice,  massage,  electricity,  etc. — these  may  act 
by  drawing  the  blood  to  the  surface  or  stimulating  the  circulation, 
thus  relieving  the  stasis  or  pressure  at  the  effected  point.  This 
theory  has  many  advocates,  and  is  one  of  the  most  rational  advanced. 

The  difference  noted  in  the  rapidity  with  which  painful  and  tactile 
impressions  travel,  and  spoken  of  elsewhere,  is  not  al  all  incompat- 
ible with  the  theory,  for  pain  being  an  abnormal  sensation  greater 
resistance  may  be  offered  to  the  transmission  of  the  more  violent  and 
abnormal  vibrations. 

In  connection  with  the  theory  that  motion  of  nerve  tissue  is 
necessary  for  function,  may  it  not  be  that  in  producing  anesthesia 
by  infiltration,  particularly  when  using  sterile  water,  that  the  swell- 


44  LOCAL   ANESTHESIA 

ing  of  the  cells  induced  by  their  taking  up  water  (and  in  this  case 
giving  off  salts)  may  so  interfere  with  their  vibration  as  to  prevent 
the  transmission  of  painful  impressions. 

This  analgesic  effect  of  the  absorption  of  hypotonic  solutions  does 
not  necessarily  contradict  the  above-mentioned  views  of  some  authors, 
for,  as  shown  elsewhere,  as  originally  proved  by  Schleich,  it  is  only 
hypotonic  solutions  which  possess  this  power;  isotonic  solutions  when 
injected  have  no  effect  upon  sensation  and  hypertonic  actually  cause 
pain. 

PHILOSOPHY  OF  PAIN 

Numerous  writers  and  thinkers  have  devoted  much  time  to  the 
philosophy  of  pain,  and  much  that  is  worthy  of  the  time  and  attention 
of  physicians  has  been  written  on  this  subject. 

Plato  and  Aristotle  have  well  said  that  neither  pure  pleasure  nor 
unqualified  displeasure  exist  in  man.  Both  feelings  are  mixed  in 
unequal  proportions  by  the  subtile  art  of  Nature,  and  the  definite  im- 
pression on  our  consciousness  is  a  resultant  in  which  one  or  the  other 
dominate.  Pain  is  due  to  exhaustion,  destruction,  or  rupture  of  sen- 
sitive tissue;  an  increase  of  expenditure,  with  insufficient  reparation, 
produces  fatigue  and  positive  pain.  All  suffering  is  partial  death 
which  comes  upon  some  organ  or  function. 

"Pain  is  not  to  be  reckoned  as  abnormal,  but  as  Nature's  protest 
against  the  abnormal.  It  is  her  finger  sternly  pointing  the  other 
way  that  she  means  us  to  go"  (Crutcher). 

The  more  consideration  which  we  give  to  the  subject,  the  more 
convincing  becomes  the  proofs  that  the  painful  sensibility  of  the 
skin  is  a  benevolent  provision,  making  us  conscious  of  those  injuries 
which,  but  for  this  quality  of  the  nervous  system,  would  bruise  and 
destroy  the  internal  and  vital  parts  which  have  little  sensation.  In 
the  first  place,  we  must  consider  that  if  a  sensibility  similar  to  that 
of  the  skin  had  been  given  to  these  internal  parts,  it  would  either 
have  remained  unexercised  or  have  made  us  painfully  conscious  of 
our  normal  organic  functions.  Had  they  been  made  sensible  to 
pricking,  burning,  etc.,  they  would  have  possessed  a  quality  which 
would  never  have  been  useful,  since  no  such  injuries  could  reach  them, 
or  only  after  ample  warning  had  been  given  through  the  sensitive 
skin,  and  it  would  further  inflict  needless  and  unnecessary  pain. 
The  deeper  parts  have  different  kinds  of  sensations,  but  a  limited 
degree  of  sensibility,  for  they  may  be  injured  without  injury  to  the 
skin,  as  in  fractures,  etc. 


NERVES   AND   THEIR   SENSATIONS ESPECIALLY  PAIN  45 

"If  we  could  imagine  beings  to  have  ever  been  created,  by  any 
sport  of  nature,  whose  pleasure  was  connected  with  injurious 
actions  and  their  pains  with  useful  ones,  they  must  have  died  out 
speedily  by  virtue  of  the  vice  in  their  constitutions." 

''All.  suffering  is  a  partial  death  which  comes  upon  some  organ 
or  function"  (Fouillee). 

To  suppose  that  we  could  be  moved  by  solicitations  of  pleasure, 
and  have  no  experience  of  pain,  would  be  to  place  us  where  injuries 
would  meet  us  at  every  step  and  in  every  motion,  and,  whether  felt 
or  not,  would  be  destructive  to  life.  To  suppose  that  we  were  to 
move  and  act  without  experiences  of  resistance  and  of  pain  is  to  sup- 
pose not  only  that  man's  nature  be  changed,  but  the  whole  of  the 
exterior  nature  also.  There  must  be  nothing  to  bruise  the  body  or 
hurt  the  eye,  nothing  noxious  to  be  drawn  in  with  the  breath.  In 
short,  it  is  to  imagine  altogether  another  state  of  existence.  Pain 
is  the  necessary  contrast  to  pleasure;  it  ushers  us  into  existence  or 
consciousness;  it  alone  is  capable  of  exciting  the  organs  into  activity. 
It  is  the  companion  and  guardian  of  human  life. 

In  a  broader  conception  of  the  statement  we  know  of  no  instance 
of  pain  being  bestowed  as  a  source  of  suffering  or  punishment,  purely, 
without  rinding  it  overbalanced  by  great  and  essential  advantages, 
and  without  being  forced  to  admit  that  no  happier  contrivance  could 
be  found  for  the  protection  of  the  body. 


CHAPTER  III 
OSMOSIS  AND  DIFFUSION 

THE  consideration  of  the  subject  of  osmosis  brings  up  many  diffi- 
cult problems,  and  it  is  necessary  that  the  reader  reach  a  f?ir  under- 
standing of  the  action  of  fluids  of  different  osmotic  pressure,  when 
injected  into  the  body  tissues.  At  one  time,  following  the  discovery 
of  osmosis  by  De  Vries  and  his  co-workers,  the  problem  was  thought 
solved,  and  was  supposed  to  be  limited  to  crystalloids  or  substances 
capable  of  solution,  while  colloids  either  did  not  diffuse  at  all  or  only 
with  great  difficulty;  since  then,  as  the  result  of  the  labors  of  many 
able  investigators,  the  subject  has  been  found  to  be  not  so  simple. 
The  perfection  of  delicate  instruments  and  improved  methods  of 
observation  have  shown  that  the  process,  when  applied  to  the  move- 
ments of  fluids  within  the  human  body,  may  at  times  be  extremely 
complicated  and  influenced  by  many  factors  which  escaped  the 
observation  of  the  earlier  investigators,  and  is  to-day  crowded  with 
problems  difficult  of  solution,  the  discussion  of  which  would  take 
large  volumes.  It  would  probably  suffice,  for  all  practical  purposes 
in  a  work  of  this  kind,  to  make  a  few  general  statements  which  could 
be  applied  for  all  clinical  purposes,  but,  for  a  more  thorough  under- 
standing of  the  subject,  we  are  compelled  to  go  further  and  sum  up 
a  certain  amount  of  experimental  and  clinical  evidence  which  bears 
more  or  less  directly  upon  the  subject,  which  if  it  serves  no  other 
purpose,  will  at  least  show  some  of  the  complicated  problems  which 
surround  this  process.  In  discussing  this  subject,  if  we  advance 
from  the  simple  to  the  complex,  and  consider  the  process  as  it  takes 
place  outside  of  the  body,  we  will  ultimately  arrive  at  a  clearer 
understanding  of  some  ot  the  complicated  processes  taking  place 
within  the  body. 

If  two  solutions  are  brought  together,  containing  different  -per- 
centages of  salts  in  solution,  the  process  by  which  they  mix  is  called 
diffusion. 

If  they  are  put  in  different  containers,  separated  by  a  permeable 
animal  membrane,  they  will  also  mix  until  the  percentage  of  salts 
in  both  containers  is  equal;  this  process,  discovered  by  De  Vries,  is 
called  osmosis,  and  the  force  which  brings  it  about  osmotic  pressure. 

46 


OSMOSIS   AND   DIFFUSION  47 

The  rapidity  of  this  movement  depends  upon  the  permeability  of  the 
membrane  and  the  difference  in  the  concentration  of  the  two  solu- 
tions. During  this  process  of  interchange  a  continuous  current 
takes  place  in  both  directions,  drawing  salt  from  the  stronger  to  the 
weaker  solution  and  water  from  the  weaker  to  the  stronger  solution ; 
this  process  continues  until  the  percentage  of  salt  is  equal  in  both 
solutions,  osmotic  equilibrium  is  then  established,  and  the  resultant 
solutions  are  isotonic  with  each  other. 

If  the  contents  of  one  is  increased  over  the  other  it  is  hypertonic 
or  hyperosmotic,  and  the  one  containing  the  lesser  percentage  of  salt 
is  hypotonic  or  hyposmotic. 

The  above  is  the  process  in  its  simplest  form  outside  the  body,  but 
this  process  at  once  becomes  more  complicated  when  the  solutions 
contain  different  salts,  where  the  molecular  weight  and  diffusibility 
vary,  and  is  further  influenced  by  the  presence  in  one  or  the  other 
solution  of  a  colloid  to  which  the  membrane  is  impermeable,  but 
which  exercises  its  influence  upon  the  interchange  and  the  resulting 
tonicity  of  the  two  fluids. 

Osmotic  processes  taking  place  in  organic  life  become  extremely 
complicated,  and  play  an  important  part  in  regulating  the  tissue 
fluids  of  both  animal  and  vegetable  life.  The  life  of  the  cell  depends 
upon  a  continuous  flow  of  the  fluids  which  furnish  the  nutrient 
materials,  consisting,  for  the  most  part,  of  water,  salts,  and  albumen, 
which  are  present  in  certain  proportions. 

In  plant  life  we  do  not  have  a  complicated  vascular  system  to 
deal  with,  such  as  exists  in  animals,  which  adds  further  problems  to 
complicate  the  process;  it  was  accordingly  in  plant  life,  with  its 
simpler  physiology,  that  the  problem  was  first  understood  and  is 
still  being  studied  by  those  interested  in  this  branch  of  investigation. 

The  human  body  is  made  up  largely  of  proteins,  fats,  and  carbo- 
hydrates, all  of  complex  molecular  composition;  the  laws  of  osmosis, 
when  applied  to  such  organisms,  are  highly  complicated,  and  are  not 
yet  thoroughly  worked  out.  The  colloidal  proteins  undoubtedly  ap- 
propriate the  major  part  of  this  phenomenon,  but  the  colloidal  fats, 
or  lipoids  and  the  carbohydrates,  play  their  part  in  so  far  as  they 
have  an  affinity  for  water. 

We  can  best  obtain  a  conception  of  some  of  these  processes  by 
considering  the  action  of  certain  well-known  colloids  toward  water 
outside  of  the  body.  Fisher,  in  his  book  on  edema,  cites  the  action 
of  the  two  well-known  animal  colloids,  gelatin  and  fibrin,  toward 
water;  in  the  presence  of  water  both  swell  to  enormous  proportions, 


48  LOCAL   ANESTHESIA 

absorbing  large  quantities  of  water;  we  may  add  to  these  the  action 
of  the  vegetable  colloid  starch,  which  acts  in  a  similar  way.  The 
behavior  of  gelatin  and  fibrin  is  influenced  largely  by  the  reaction  of 
the  solution  in  which  they  are  placed,  taking  up  water  more  rapidly 
and  in  larger  quantities  when  of  slightly  alkalin  or  acid  reaction, 
however,  the  rate  of  increase  does  not  always  correspond  to  the  in- 
crease of  alkalinity  or  acidity. 

Many  colloids  may  at  times  exist  in  crystalline  condition,  such  as 
egg-albumen  and  hemoglobin;  there  also  exists  many  grades  between 
these  two  states  when  a  substance  may  have  a  tendency  in  one  or 
the  other  direction.  Fibrin,  a  typical  colloid,  is  readily  exuded  into 
the  tissue  spaces  and  as  readily  absorbed,  apparently  regardless  of 
the  laws  of  osmosis.  These  colloids  do  not  form  true  solutions,  but 
heterogeneous  solutions,  and  show  little  or  no  tendency  to  osmosis, 
yet  many  of  them  readily  pass  in  and  out  of  the  tissues;  such  of  the 
colloids  as  gelatin  and  fibrin,  which  absorb  large  quantities  of  water, 
are  said  to  be  hydrophilic. 

These,  and  other  facts  to  be  mentioned,  show  that  osmosis 
is  not  the  only  factor  at  play  in  the  movement  of  the  body-fluids. 
It  may  play  a  large  part,  but  still  leaves  many  phenomena  which 
can  now  only  be  explained  as  the  vital  functions  of  cell  life,  excre- 
tion or  absorption  as  their  function  may  be.  Cells  are  not  simply 
inert  bodies  which  absorb  or  give  off  water  to  a  surrounding  medium 
regardless  of  other  conditions,  certain  chemical  affinities  may  exist 
which  exercise  a  strong  influence  in  one  or  the  other  direction.  Thus 
Fischer,  in  writing  on  this  subject  in  regard  to  the  role  played  by 
acids  and  alkalis,  states  the  following: 

"Two  groups  of  substances  have  always  stood  out  prominently  as 
exceptions  to  the  laws  of  osmotic  pressure,  as  considered  active  in 
protoplasm,  acids,  and  alkalis.  The  various  tissue  elements  which 
have  been  examined  in  dilute  solutions  of  these  substances — red  and 
white  blood-corpuscles,  muscle,  kidney,  and  liver-cells — all  show  an 
absorption  of  water  which  is  vastly  greater  than  can  be  accounted 
for  on  the  basis  of  any  idea  of  osmotic  pressure.  In  fact,  the  amount 
that  muscle  can  swell  in  dilute  acids  has  been  employed  by  Overton 
as  a  powerful  argument  against  the  ordinary  osmotic  conception  of 
absorption  in  general.  He  has  shown  very  clearly  that  were  all  the 
proteins,  carbohydrates,  and  fats  contained  in  muscle  split  up  into 
their  simplest  products,  a  sufficient  yield  of  molecules  and  ions  would 
not  be  obtained  to  furnish  an  osmotic  pressure  adequate  to  account 
for  the  water  absorbed.  We  have  no  trouble  in  accounting  for  this 


OSMOSIS  .AND  DIFFUSION  49 

behavior  of  the  acids  and  alkalis  on  the  basis  of  our  colloidal  con- 
ception. The  acids  and  alkalis  are  the  substances  most  capable  of 
altering  the  affinity  of  the  hydrophilic  colloids  for  water. 

"The  observations  of  Hamburger,  that  the  volume  of  red  blood- 
corpuscles  and  the  diameter  of  white  blood-corpuscles  increase  pro- 
gressively with  every  increase  in  the  concentration  of  the  acid  or  the 
alkali  in  the  solutions  surrounding  them,  finds  a  ready  explanation 
in  the  facts  outlined  regarding  the  swelling  of  fibrin  and  gelatin." 

The  action  of  animal  tissue,  particularly  muscle,  has  been  studied 
in  a  similar  way. 

Loeb  showed  that  muscle  tissue  does  not  change  in  weight  if  sus- 
pended in  watery  solutions  having  the  same  osmotic  pressure  as  the 
blood,  but  that  it  gains  or  loses  weight  if  placed  in  solutions  of  higher 
or  lower  osmotic  pressure. 

This  varies  with  the  kind  of  salts  forming  the  solutions,  being 
greater  with  potassium  chlorid  than  it  is  with  NaCl  and  least  of  all 
with  calcium  chlorid. 

"A  muscle  swells  more  in  the  solution  of  any  acid  than  it  does  in 
pure  water,  but  the  amount  of  the  swelling  is  greater  in  some  acids 
than  in  others." 

"An  important  relationship  exists  between  the  concentration  of 
the  acid  employed  and  the  amount  that  the  muscle  will  swell." 

"After  a  time  a  point  is  reached  beyond  which  a  further  increase 
is  followed  by  a  diminished  absorption  of  water." 

"We  have  also  no  difficulty  in  accounting  for  the  unequal  swelling 
of  cells  in  ostomotically  equivalent  solutions.  We  have  found  the 
same  to  be  true  of  the  swelling  of  fibrin  and  gelatin.  We  have  been 
able  to  go  even  farther:  we  have  found  that  the  same  group  of  sub- 
stances which  have  proved  exceptions  in  the  osmotic  studies  on  cells 
also  show  a  like  exceptional  behavior  when  we  deal  with  fibrin." 

"To  find  an  analogue  for  the  failure  of  muscle,  red  blood-corpus- 
cles, and  cells  in  general  to  shrink  the  calculated  amount  with  every 
unit  increase  in  the  concentration  of  the  added  salt  is  also  simple. 
We  need  only  refer  once  more  to  the  experiments  on  the  swelling  of 
fibrin  and  of  gelatin,  in  which  we  found  that  here,  too,  doubling  the 
concentration  does  not  halve  the  volume ;  the  amount  of  decrease  is 
always  less  than  anticipated." 

"  It  is  somewhat  difficult  to  say  what  is  the  effect  of  alkalis  on  the 
absorption  of  water  by  muscle.  The  statement  is  unquestionably 
true  that  muscles  swell  more  in  the  solution  of  any  alkali  than  water." 

This  depended  upon  the  condition  of  muscle  (the  acid  content). 


50  LOCAL   ANESTHESIA 

"When  such  muscles  are  placed  in  alkaline  solutions  the  alkali  com- 
bine with  the  acid  and  the  salt  formed  by  the  union  inhibits  the 
swelling." 

Many  conditions  may  influence  the  process.  "It  may  at  first 
show  a  decided  decrease,  and  later  on  equally  decided  increase,  or  the 
reverse  may  be  the  case." 

"The  addition  of  any  salt  to  the  solution  of  an  acid  decreases  the 
amount  that  a  muscle  will  swell  in  that  solution,  and  the  higher  the 
concentration  of  the  salt  the  greater  is  the  amount  of  this  inhibition," 
but  different  salts  act  unequally  in  this  respect.  Cases  illustrating 
the  spread  of  anesthetic  solutions  by  diffusion  through  the  tissues, 
where  osmosis  must  play  a  small  part,  is  seen  in  the  wide  distribution 
of  anesthesia  following  massive  infiltrations,  when  the  anesthesia 
spreads  quite  a  distance  beyond  the  site  of  injection;  also  in  hypo- 
dermoclysis  the  fluid  is  seen  to  diffuse  over  a  wide  area;  similarly  in 
Bier's  vein-anesthesia,  the  solution  filters  through  the  vein  wall  under 
pressure  and  diffuses  through  the  entire  thickness  of  the  limb;  such 
extensive  permeation  would  hardly  be  expected  from  osmosis  alone. 
We  must  also  not  lose  sight  of  the  fact  that  in  the  human  body  we  are 
dealing  with  a  circulatory  apparatus,  and  that  the  pressure  in  the 
vessels  is  always  greater  than  in  the  cellular  interspaces,  and  that  the 
bulk  of  the  absorption  is  done  by  the  capillaries  (lymphatics  playing 
but  a  small  part).  While  it  is  not  impossible  for  salts  in  a  solution 
under  less  pressure  to  find  their  way  by  osmosis  into  a  solution  under 
greater  pressure,  it  is  nevertheless  likely  that  in  such  a  vital  process 
as  absorption  that  osmosis  must  play  a  minor  role,  the  same  as  seen 
in  the  absorption  of  fluids  from  the  intestinal  tract. 

Theoretically,  according  to  the  laws  of  osmosis,  a  hypertonic 
solution  should  be  absorbed  more  slowly  than  a  hypotonic  one,  as  the 
fluid  must  first  be  rendered  isomotic  before  absorption  can  take  place. 
The  hypertonic  solution  must  first  abstract  enough  water  from  the 
surrounding  tissues,  while  largely  retaining  its  salts,  until  it  becomes 
isotonic,  then  absorption  can  take  place.  A  hypotonic  solution 
begins  at  once  to  give  up  its  water.  According  to  the  above,  on 
theoretic  grounds  at  least,  the  salts  contained  in  a  hypertonic  solution 
should  be  retained  in  situ  longer,  and  in  the  case  of  anesthetic  solu- 
tions produce  a  longer  anesthesia.  In  considering  this  question, 
however,  we  must  not  lose  sight  of  the  fact  that  osmosis  is  a  purely 
chemicophysical  process  which  takes  place  through  a  membrane,  and 
cannot  be  unqualifiedly  applied  to  living  tissue,  which  exercises 
certain  physiologic  functions  and  may  absorb,  regardless  of  the  laws 


OSMOSIS   AND   DIFFUSION  51 

of  osmosis,  in  much  the  same  way  as  fluids  are  absorbed  from  the 
alimentary  canal.  That  osmosis  does  play  a  certain  part  we  must 
concede,  and  that  we  can  favor  this  process  by  bringing  about  con- 
ditions which  will  act  favorably.  Thus,  it  has  been  shown  that 
dilute  acids  and  alkalis  favor  this  process,  more  particularly  acids; 
alkalis,  the  weaker  of  the  two  in  this  respect,  will  not  be  considered, 
and  should  be  carefully  avoided  in  all  anesthetic  solutions,  as  their 
presence  produces  a  decomposition  of  nearly  all  the  anesthetic  salts 
used. 

On  the  other  hand,  acids  are  favorable  to  the  stability  of  the 
anesthetic  salts,  which  are  acid  derivations;  the  presence  of  small 
quantities  of  NaCl  and  adrenalin  solution  used  in  most  anesthetic 
solutions,  both  of  which  have  slight  acid  reactions,  are  sufficient  for 
our  purpose,  and  enhance  decidedly  the  absorption  of  the  injected 
solution  by  the  tissues.  The  presence  of  more  than  a  minute  trace 
of  acid  is  hemolytic  in  its  action  upon  the  blood-corpuscles  and  so 
further  additions  are  prevented. 

Considering  osmotic  processes  governing  fluids  injected  into  the 
tissues,  we  must  also  bear  in  mind  that  these  laws  govern  fluid  under 
equal  tension,  and  when  the  tension  of  one  or  the  other  is  increased 
the  fluid  under  greater  tension  is  forced  into  the  other  by  filtration. 
Consequently,  when  we  infiltrate  the  tissues  with  anesthetic  solutions 
under  pressure  regardless  of  its  being  hypotonic,  isotonic,  or  hyper- 
tonic,  the  injected  solution,  in  consequence  of  this  pressure,  diffuses 
in  all  directions,  regardless  of  the  laws  of  osmosis,  and  it  is  only  when 
lightly  injected,  in  small  quantities  or  in  loose  tissues,  that  osmosis 
plays  any  decided  part  in  the  diffusion  and  absorption  which  takes 
place.  Hypertonic  solutions  may  be  absorbed  with  less  rapidity 
than  isotonic  or  hypotonic  ones.  We  are  not  concerned  so  much  with 
the  value  of  the  solutions  from  this  standpoint  as  we  are  in  selecting 
solutions  which  have  no  injurious  action  upon  the  tissues,  for,  since 
the  introduction  of  adrenalin,  we  are  able  to  control  to  a  great  extent 
the  rapidity  of  absorption  from  the  site  of  injection  into  the  general 
circulation  by  the  use  of  this  agent. 

The  effect  of  adrenalin  in  influencing  the  osmosis  and  absorption 
of  fluids  injected  into  the  tissues  must  also  be  considered;  where 
the  circulation  is  decidedly  lessened  or  almost  entirely  arrested 
(except  in  very  vascular  parts)  by  the  use  of  this  agent,  osmosis  has 
a  better  opportunity  to  exercise  its  influence  than  in  the  presence 
of  an  active  circulation.  Nose  and  throat  specialists,  who  use  con- 
centrated solutions  with  a  large  content  of  adrenalin,  are  able  to 


52  LOCAL   ANESTHESIA 

closely  observe  its  effect.  Many  such  operators  claim  less  constitu- 
tional effect  from  the  same  amount  of  the  anesthetic  agent,  in  concen- 
trated form,  that  would  be  the  case  in  using  a  larger  quantity  of  a 
weaker  solution;  most  nose  and  throat  specialists  still  prefer  to  use 
cocain,  which  also  exerts  a  vasoconstrictor  effect.  Solutions  of  high 
density  are  not  readily  absorbed  by  the  blood-vessels,  and  by  the 
time  they  are  sufficiently  diluted  to  be  absorbed  the  circulation  has 
been  largely  arrested  by  the  adrenalin  plus  the  vasoconstriction  effect 
of  cocain,  if  that  agent  is  used.  When  injected  into  practically  ische- 
mic  tissues,  or  tissues  quickly  rendered  ischemic,  the  concentrated 
anesthetic  osmoses  into  the  surrounding  cells  and  is  largely  fixed  by 
them,  and  is  only  washed  out  by  the  returning  circulation,  which  is 
delayed  or  held  in  check  by  small  quantities  of  the  drug  as  it  is  being 
absorbed.  In  this  way  many  of  them  explain  the  facility  with  which 
they  use  such  strong  solutions. 

The  following  well-recognized  laws  of  physiology  explain  the 
local  retention  in  the  parts  of  strong  cocain-adrenalin  solutions  and 
the  prolonged  anesthesia  and  ischemia  following  its  use: 

1.  A  fluid  passes  through  a  membrane  with  a  rapidity  inversely 
proportional  to  the  destiny  of  the  fluid. 

2.  The  rate  of  absorption  varies  directly  with  the  fulness  and 
tension  of  the  blood-vessels  and  lymphatics. 

3.  The  slower  the  movement  of  the  blood  and  lymph-streams  the 
slower  will  be  the  rate  of  the  absorption  of  the  fluids. 

In  tissues  rendered  ischemic  from  the  use  of  an  Esmarch  bandage, 
or  by  gravity  with  a  constrictor,  injected  solutions  have  a  better 
opportunity  to  enter  the  tissue-cells  and  exert  the  maximum  effect, 
though  a  limited  amount  of  circulation  may  be  favorable  to  a  distribu- 
tion of  the  injected  solution,  and  the  same  effect  can  be  obtained  by 
massage. 

As  the  object  of  this  discussion  is  to  develop  a  thorough  under- 
standing of  the  best  way  and  means  to  produce  an  anesthesia  of 
surgical  intensity  and  of  sufficient  duration  and  extent  to  serve 
every  purpose,  we  have  seen  that  osmosis  can  play  but  a  limited 
part;  the  body-fluids  are  in  motion  within  the  vessels,  and  the  anes- 
thetic is  constantly  being  carried  away.  As  will  be  shown  the  ac- 
tion of  any  anesthetic  is  increased  by  a  sojourn  in  the  tissues; 
arrest  or  absolute  stilling  of  the  circulation,  as  obtained  by  the  con- 
striction of  adrenalin,  favors  this  effect.  Our  object,  then,  is  to 
develop  an  anesthetic  solution  which  will  possess  as  many  of  the 
desirable  qualities  as  possible,  and  at  the  same  time  prove  non- 


OSMOSIS   AND   DIFFUSION  53 

injurious  to  the  tissues.  A  NaCl  solution,  containing  0.97  per  cent., 
is  isosmotic  for  human  blood-serum,  a  physiologic  salt  solution,  and 
has  a  freezing-point  at  .56°C.,  although  red  and  white  corpuscles 
are  affected  different  by  changes  in  the  strength  of  solution  as  well 
as  by  the  kind  of  salts  used,  yet  these  changes  are,  for  the  most  part, 
slight,  and  for  all  practical  purposes  where  NaCl  is  the  salt  used, 
as  in  the  accepted  anesthetic  solutions  of  to-day,  the  above  should 
serve  as  a  basis  for  calculation. 

The  simplest  method  of  determining  the  osmotic  tonicity  of  a 
solution  as  compared  to  another  is  to  determine  their  freezing-points ; 
this,  however,  does  not  always  decide  whether  or  not  a  solution  is 
best  for  our  purposes.  Many  solutions  may,  as  far  as  their  os- 
motic tension  is  concerned,  be  perfectly  isotonic  with  blood-serum, 
yet  their  contained  salts  exert  a  hemolytic  influence  upon  the  blood- 
corpuscles,  as  will  be  shown  in  discussing  the  different  agents  used, 
and  as  pointed  out  by  Barker  in  the  case  of  stovain,  which  is  dis- 
cussed in  greater  length  in  the  chapter  on  Spinal  Analgesia. 

If  a  physiologic  salt  solution,  0.97  per  cent.  NaCl,  is  slowly  in- 
jected at  body  temperature  into  the  loose  connective  tissue  of  the 
body  in  moderate  quantity,  neither  swelling  or  shrinkage  of  the 
cells  is  produced,  and  no  after-irritation  results,  consequently  no 
pain  is  felt.  If  instead  simple  distilled  water  be  injected,  pain  is 
produced,  due  to  an  abstraction  by  the  water  of  the  salts  contained 
within  the  surrounding  cells,  while  the  cells  absorb  water  causing 
them  to  swell,  thus  macerating  their  contents,  which  may  result  in 
the  death  of  the  cell;  after  the  initial  pain  of  the  injection  has  sub- 
sided a  certain  degree  of  anesthesia  is  obtained,  the  "anesthesia 
dolorosa"  of  Liebreich.  If  concentrations  of  NaCl  greater  than 
0.97  per  cent,  are  used,  the  solution  abstracts  water  from  the  cells 
and  causes  them  to  shrink,  giving  rise  to  more  or  less  pronounced 
pain.  These  manifestations  are  proportionally  the  more  intense 
the  greater  the  concentration  of  the  solution,  until  tissue  disturb- 
ances may  result  which  may  terminate  in  gangrene. 

The  relative  freezing-points  of  a  large  number  of  solutions  com- 
pared with  blood-serum  has  been  worked  out  by  Prof.  Braun.  We 
quote  the  following  from  his  recent  work,  as  well  as  copy  the  table 
(Fig.  i)  which  he  has  prepared: 

"On  the  horizontal  line  we  find  a  list  of  the  saline  solutions  from 
o  per  cent,  (plain  water)  to  10  per  cent.;  of  some  of  these  solutions 
the  freezing-points  are  given.  The  black  curve  represents  sensory 
stimulation,  which  is  felt  as  pain  when  the  solutions  are  injected  into 


54 


LOCAL  ANESTHESIA 


the  cuticle ;  the  dotted  curve  shows  the  sensory  paralysis  (anesthesia) 
which  follows  this  stimulus;  the  distance  between  the  two  curves 
at  any  one  point  corresponds  with  the  relative  intensity  of  the  stimu- 
lus and  the  paralysis.  The  central  point  is  occupied  by  the  saline 
solution  of  0.9  per  cent,  with  a  freezing-point  of  —  55°C.  This  solu- 
tion has,  therefore,  about  the  same  osmotic  tension  as  human  blood ; 
all  solutions  on  the  left  causing  a  swelling  of  the  tissues,  while  those 
on  the  right  extract  water  from  them." 

If  the  0.9  per  cent,  saline  solution  is  injected  into  the  cuticle  at 
body  temperature  no  pain  is  felt,  no  stimulation  is  induced,  nor  can 
any  change  of  sensibility  be  observed  in  the  region  of  the  welt,  espe- 
cially no  sensory  diminution.  The  welt  thus  produced  disappears  very 
soon  without  leaving  any  trace.  If  we  now  gradually  decrease  the 


Irritation 
Anesthesia. 


freeziny  /""VT^? 
Na.cl.  sol. < 


Coeain  sot.  _____ 
Eucatfi 


....7* _. 


t\        *t        » 

........  —  -*P-  ----  4s-  ...........  - 


tScfileich  SoLl  _____  .....  -  .......  I    freeziitf  point-    o./ss' 


Human  Blood. 


Fig.  i.  —  Diagrammatic  representation  illustrating  the  irritating  and  anesthetic 
action  of  various  hypo-  and  hypertonic  solutions  on  the  tissues  compared  with  human 
blood  (after  Braun). 

strength  of  the  solution,  pain  appears  on  injection,  usually  around 
0.55  per  cent.  On  further  dilution  this  pain  quickly  increases  in 
intensity  and  reaches  its  maximum  when  pure  water  is  used. 

"This  latter  injection  is  extremely  painful;  this  pain  which  we 
call  welt  pain  is  only  of  short  duration,  and  is  followed  by  a  diminu- 
tion and  then  cessation  of  pain  in  the  injected  area.  The  inten- 
sity and  duration  of  this  phenomenon  gradually  increases  and  lasts 
longest  (about  fifteen  minutes)  with  pure  water.  We  call  it  'welt 
anesthesia.'  Very  dilute  solutions  cause  an  injury  to  the  tissues, 
that  shows  itself  in  a  painful  infiltration  at  the  site  of  injection.  Pure 
water  causes,  in  a  number  of  cases,  superficial  necrosis  of  the  tissues, 
"infiltration  necrosis.' 

"With  solutions  containing  more  than  0.9  per  cent,  sodium  chlorid 


OSMOSIS    AND    DIFFUSION  55 

the  symptoms  caused  by  their  affinity  for  water  can  be  observed. 
These  symptoms  also  consist  in  stimulation,  paralysis,  and  tissue 
injury. 

"But  the  stimulation  manifests  itself  in  a  different  way  than  in 
the  'welt  pain ' ;  it  follows  the  injection,  which  in  itself  is  painless  and 
lasts  for  several  minutes,  the  site  of  the  injection  being  strongly 
hyperesthetic ;  this  is  followed  by  anesthesia.  The  welt  at  the  same 
time  shows  very  peculiar  and  typical  changes  of  form;  when  the 
burning  pain  commences  to  diminish  and  the  anesthesia  begins  the 
center  of  the  welt  rapidly  sinks  down  and  forms  a  depression,  while 
the  margin  forms  a  circular  raised  wall.  The  anemic  margin  and 
the  anemic  center  are  generally  separated  by  a  narrow  red  ring; 
after  about  fifteen  minutes  the  welt  again  grows  uniformly  flat  and 
its  periphery  becomes  larger;  finally,  it  disappears  and  sensation 
returns.  These  concentrated  saline  solutions  damage  the  tissues. 
All  these  symptoms  grow  more  intense  with  the  increasing  strength 
of  the  solution.  With  2.5  per  cent,  they  are  already  noticeable, 
and  injection  of  saline  solutions  of  more  than  10  per  cent,  can  scarcely 
be  tolerated.  A  small  degree  of  infiltration  and  taking  up  of  water 
cannot  be  observe'd;  hence,  there  exists  around  the  0.9  per  cent,  saline 
solution  an  indifferent  zone,  comprising  a  number  of  solutions  (from 
0.55  to  2.5  per  cent.),  which  do  not  cause  the  above-mentioned 
symptoms. 

"But  it  must  be  remembered  that  the  curves  showing  the  pain 
and  sensory  reduction  do  not  represent  absolute  values.  They  were 
the  result  of  experiments  on  the  skin  of  our  own  forearms.  If  saline 
solutions  are  injected  in  hyperesthetic  tissues,  or  in  very  sensitive 
persons,  solutions  of  less  strength  will  cause  the  above-mentioned 
symptoms.  The  curves  will  here  reach  the  horizontal  line  nearer  its 
center  than  in  our  experiments,  and  the  apparently  indifferent  zone 
will  be  narrower"  (Braun). 

But  little  work  has  been  done  on  the  osmotic  pressure  exercised 
by  the  various  local  anesthetic  agents  and  their  hemolytic  effect 
upon  the  blood.  As  the  hemolytic  action  of  any  agent  is  of  prime  im- 
portance, the  following  conclusions,  drawn  by  Biinte  and  Moral,  which 
deals  particularly  with  novocain,  the  anesthetic  salt  now  attracting 
the  most  favorable  attention,  are  deserving  of  consideration: 

"i.  The  enveloping  membrane  of  blood-corpuscles  is  perfectly 
permeable  for  novocain,  tropococain,  etc. 

"  2.  Novocain  solutions,  etc.,  should  never  exercise  an  osmotic  in- 
fluence on  blood-corpuscles. 


56  LOCAL   ANESTHESIA 

"3.  Novocain  solutions,  to  be  iso tonic  for  blood-corpuscles, 
should  be  dissolved  in  a  solution  containing  0.29  per  cent.  NaCl. 

"4.  Novocain  exercises  a  slight  hemolytic  action,  which,  in  the 
presence  of  a  0.29  per  cent.  NaCl  solution  and  when  the  novocain  is 
not  too  concentrated,  disappears  completely. 

"5.  Solutions  of  novocain  in  0.625  Per  cent.  NaCl  solution  do  not 
cause  hemolysis,  but  produce  a  swelling  of  the  blood-corpuscles;  after 
prolonged  standing  the  corpuscles  show  distinct  signs  of  beginning 
hemolysis. 

"6.  If  the  content  of  a  novocain-saline  solution  is  0.6  per  cent., 
NaCl  or  less  hemolysis  does  occur. 

"7.  The  values  of  lowering  the  freezing-point  found  in  the 
Beckmann  apparatus  on  a  novocain-saline  solution  cannot  without 
any  further  work  be  applied  to  the  calculations  of  the  osmotic  pres- 
sure of  blood-corpuscles. 

"8.  No  alkali,  or  even  salts  with  alkaline  reaction,  can  be  added 
to  the  novocain-saline  solution,  since  a  precipitation  of  the  novocain 
would  occur. 

"9.  The  2  per  cent,  novocain  solution  can,  without  diminishing 
its  action,  be  reduced  to  1.5  per  cent,  with  children  and  feeble  indi- 
viduals, even  so  far  as  0.5  per  cent. 

"  10.  Solutions  containing  non-indifferent  substances  are  unfit 
for  injection;  as  such  are  to  be  considered  alcohol-ether  injections 
(after  Eckstein),  since  they  coagulate  the  blood-corpuscles. 

"n.  The  1.5  and  0.5  per  cent,  novocain-saline-thymol  solution, 
the  end-result  of  our  examinations,  have  come  up  to  all  expected 
requirements,  theoretic  as  well  as  practical. 

"Its  osmotic  pressure  is  equal  to  that  of  the  tissues,  they  have  no 
hemolytic  action  on  the  blood-corpuscles  and  produce  no  injury  to 
the  tissues." 

After  a  consideration  of  the  foregoing,  the  selection  of  a  men- 
struum for  anesthetic  agents  becomes  a  matter  of  considerable  im- 
portance. The  use  of  distilled  water,  as  practised  by  some,  while 
under  some  conditions  producing  fair  surgical  analgesia,  is  hardly  to 
be  recommended  for  any  extensive  operative  undertaking,  as,  on 
physiologic  grounds,  it  may  be  followed  by  sufficient  injury  to  the 
tissues  to  lead  to  necrosis.  For  similar  reasons  the  0.2  per  cent,  solu- 
tions of  NaCl,  as  recommended  by  Schleich,  has  not  been  followed 
by  us,  although  producing  good  anesthesia,  and,  we  must  admit, 
yielding  good  results  clinically  in  the  healing  of  wounds.  In  the 
light  of  physiologic  investigations  the  osmotic  tension  is  too  low; 


OSMOSIS    AND    DIFFUSION  57 

it  is  probable  that  less  injury  would  result  and  less  after -pain  occur 
from  the  use  of  a  solution  containing  slightly  more  NaCl.  It  is  for 
that  reason  that  we  have  adopted  solutions  containing  0.4  per  cent. 
NaCl,  which,  however,  according  to  physiologic  observations,  is 
still  low  enough  to  produce  decided  hemolysis,  yet  we  have  never 
observed  any  unpleasant  action  from  its  use  in  several  hundred  cases, 
but  believe  that  there  is  a  slight  advantage  in  its  favor,  in  that  there 
was  less  after-pain  and  soreness  complained  of  following  its  use,  par- 
ticularly in  large  operations,  than  when  using  solutions  of  lower 
concentration. 

Schleich  claims  for  his  solutions  that  the  anesthesia  is  largely  due 
to  their  hypotonicity,  upon  which  they  largely  depend  for  their 
action,  the  content  of  anesthetic  salts  serving  principally  to  lessen  the 
pain  of  infiltration.  While  their  anesthetic  influence  is  unquestion- 
ably enhanced  by  their  hypotonicity,  their  anesthetic  content,  though 
weak,  is  still  sufficient,  when  the  tissues  are  thoroughly  saturated, 
to  exert  a  decided  anesthetic  influence,  as  can  be  proved  by  using  the 
same  strength  of  cocain  and  other  salts  dissolved  in  normal  salt  solu- 
tion. While  clinically  we  have  no  fault  to  find  with  Schleich's  solu- 
tions after  an  extended  use  covering  many  years,  yet,  in  the  light  of 
our  present  knowledge,  on  physiologic  grounds  we  feel  that  a  nearer 
approach  to  an  isotonic  solution  with  human  blood  would  have  its 
advantage  and  throw  less  traumatic  burden  upon  the  tissues  in  the 
operative  field;  we  have  accordingly,  for  this  reason,  preferred  to  use 
0.4  per  cent,  salt  solutions. 

Braun,  in  his  solutions,  uses  0.8  per  cent,  sodium  chlorid  for 
ordinary  purposes  of  infiltration,  but  when  stronger  solutions  are 
used  for  special  purposes  he  reduces  the  content  of  the  NaCl 
proportionately. 


CHAPTER  IV 

THE  ANESTHETIC  EFFECTS  OF  PRESSURE-ANEMIA— 
COLD  AND  WATER  ANESTHESIA 

PRESSURE 

PROLONGED  pressure  upon  a  nerve  paralyzes  its  function,  either 
motor,  sensory,  or  both.  This  is  seen  in  many  illustrations  in  daily 
life,  such  as  when  the  leg  "goes  to  sleep"  after  crossing  it,  becoming 
numb  and  difficult  of  motion  for  a  few  minutes.  In  sleeping  with  the 
arms-  above  the  head,  by  pressure  of  the  clavicle  upon  the  brachial 
plexus,  one  may  awaken  with  a  feeling  as  if  the  arms  were  dead;  it 
may  require  some  effort  to  lower  them,  when  the  feeling  soon  passes 
off. 

This  pressure,  if  persisted  in  for  a  sufficient  length  of  time,  and 
particularly  if  combined  with  anemia  of  the  part,  may  produce  such 
a  degree  of  paralysis  that  the  parts  are  practically  analgesic,  when 
it  is  possible  to  perform  peripheral  operations  with  little  or  no  pain. 
However,  pressure,  persisted  in  to  this  extreme  degree,  becomes 
highly  dangerous,  and  may  be  followed  by  serious  consequences  as  a 
result  of  traumatic  neuritis  of  the  nerve-trunks,  leading  in  extreme 
cases  to  possible  atrophic  changes;  this  is  seen  usually  in  mild  form  in 
crutch  paralysis,  or  in  paralysis  of  the  upper  extremity  following  anes- 
thesia, when,  during  complete  muscular  relaxation,  the  arms  are 
held  above  the  head,  causing  the  clavicle  to  compress  the  brachial 
plexus. 

These  consequences  sometimes  follow  the  injudicious  use  of  the 
Esmarch  constrictor,  but  here  it  is  more  especially  the  circulation 
which  is  interrupted,  though  occasionally  damage  may  result  from 
pressure  upon  the  nerves. 

These  procedures,  resorted  to  in  earlier  days,  were  the  best  that 
the  surgeons  then  had  at  their  command,  as  they  knew  nothing 
about  exsanguination;  the  constrictor  was  placed  upon  the  limb 
with  its  full  content  of  blood  within  the  parts,  and  was  used  more  to 
prevent  hemorrhage  than  to  obtund  nerve  sensibility,  though  some 
made  use  of  it  for  this  purpose.  In  either  case  the  patient  was 
generally  narcotized  with  alcoholics  and  drugs  in  use  at  the  time. 

It  is  highly  probable  that  prehistoric  man  made  use  of  these 

58 


THE  ANESTHETIC  EFFECTS  OF  PEESSUEE-ANEMIA  59 

physical  means,  as  well  as  the  application  of  cold  (ice  or  snow)  to 
lessen  sensibility,  as  these  practices  are  in  use  to-day  among  un- 
civilized races,  and  are  handed  down  by  tradition  from  one  genera- 
tion to  another.  The  carotid  arteries  were  called  by  some  of  the 
ancients  the  arteries  of  sleep,  as  prolonged  pressure  upon  them  pro- 
duced sleep,  and  this  practice  has  been  reported  to  have  been  in  use 
in  fairly  recent  times. 

It  must,  however,  be  borne  in  mind  that,  while  the  resulting 
peripheral  paralysis  (motor  and  sensory)  becomes  more  pronounced 
the  longer  the  pressure  is  continued,  the  discomfort  at  the  point  of 
constriction  is  also  progressively  increasing  the  longer  it  is  main- 
tained, until  it  becomes  decidedly  painful,  and  may  become  un- 
bearably so  before  any  very  decided  impression  is  made  upon  the 
peripheral  sensibility. 

The  ability  of  the  patient  to  stand  an  effective  amount  of  pressure 
will  of  course  be  determined  to  a  large  extent  upon  the  care  with 
which  the  constrictor  is  applied;  the  same  amount  of  pressure,  if  ap- 
plied to  a  narrow  area  by  applying  the  successive  rolls  of  the  con- 
strictor one  on  top  the  other,  becomes  much  more  painful  than  when 
the  successive  rolls,  are  applied  progressively  to  a  higher  or  lower 
level  of  the  limb,  thus  embracing  a  wider  area.  This  care  in  having 
the  parts  well  padded  before  applying  the  constrictor  has  much  to  do 
with  the  ability  of  the  patient  to  comfortably  stand  the  needed  pres- 
sure. While  we  now  never  use  constriction  or  pressure  for  the  pur- 
poses discussed  here,  these  facts  must  be  borne  in  mind  in  applying 
a  constrictor  to  a  limb  for  the  purposes  of  ischemia  when  operating 
under  local  anesthesia,  when  it  is  very  unpleasant  to  stop  during  the 
progress  of  an  operation  to  loosen  an  uncomfortably  tight  constric- 
tor. The  stoutness  of  the  patient  is  also  a  factor  which  must  be  con- 
sidered in  applying  a  constrictor;  the  required  amount  of  pressure 
must  necessarily  be  much  greater  over  a  stout  limb  than  over  a  thin 
or  emaciated  one,  and  should  be  graduated  accordingly. 

The  use  of  constriction  for  holding  local  anesthetic  solutions 
in  situ  will  be  spoken  of  elsewhere. 

The  benumbing  effect  of  long-continued  pressure  upon  any 
part  of  the  body  is  well  known;  although  some  pain  may  be  pro- 
duced in  the  surrounding  parts,  it  is  possible  to  carry  it  to  a  point 
of  depressing  both  tactile  and  painful  impressions  to  a  consider- 
able degree;  this  is  brought  about  in  two  ways,  first  the  compres- 
sion directly  paralyzes  the  nerve-endings  of  the  part,  and,  secondly, 
the  anemia  intensifies  this  effect. 


60  LOCAL   ANESTHESIA 

COLD 

It  is  highly  probable  that  the  first  use  of  cold  for  its  sedative 
effect  must  have  occurred  in  the  remote  past.  Primitive  man,  with 
his  meager  supply  of  aids  and  necessities,  most  likely  made  use  of  all 
physical  means  at  his  command. 

Military  history  contains  many  references  to  the  sedative  and 
analgesic  effect  of  cold.  Larrey,  Napoleon's  chief  surgeon,  reports 
that  at  the  battle  of  Eylau,  with  a  temperature  of  —  i9°F.,  that 
peripheral  wounds  caused  very  little  suffering,  and  that  amputations 
were  practically  painless  when  the  limbs  were  first  freely  exposed  to 
the  air. 

The  first  record  we  have  of  the  use  of  cold  in  modern  surgery  was 
by  Arnott  in  1848,  who  employed  bags  or  bladders  filled  with  ice  and 
salt  for  their  depressing  or  sedative  effect  upon  the  sensibility  of  the 
part. 

The  usual  means  by  which  cold  is  employed  for  its  local  anesthetic 
effect  in  modern  surgery  is  by  the  use  of  various  gases  or  liquids  of  low 
boiling-point,  which  are  usually  projected  in  the  form  of  a  spray  upon 
the  skin,  their  rapid  evaporation  producing  an  intense  cold  which 
freezes  the  parts. 

Sulphuric  ether  was  the  first  agent  used  in  this  way.  The  first 
atomizer  or  spraying  apparatus  was  devised  by  Richardson  in  1866, 
and  furnished  the  idea  for  all  such  instruments  in  use  to-day.  It 
was  found  that  a  perfectly  pure,  water-free  ether  was  necessary, 
such  as  that  used  for  anesthesia;  it  should  have  a  specific  gravity  of 
0.720,  and  boil  at  34-5°C. 

It  was  later  found  that  many  substances  other  than  sulphuric 
ether  could  be  used  for  the  same  purpose,  and  the  lower  the  boiling- 
point  the  more  intense  was  the  cold  generated  by  their  evaporation. 

These  agents  belong  principally  to  the  ethyl  or  methyl  groups. 
Ethyl  chlorid  (C2H5C1),  known  under  various  trade  names  as  kelene 
or  antidolorin,  and  also  called  hydrochloric  ether,  is  used  for  both 
general  and  local  anesthesia;  it  is  a  colorless  gas,  liquified  in  tubes, 
and  has  a  boiling-point  at  i2.5°C.;  was  first  introduced  by  Rotten- 
stein,  and  has  proved  the  most  satisfactory  and  useful  of  all  these 
agents. 

In  the  methyl  group  there  are  several  local  anesthetics;  methyl 
iodid  (CH3I)  is  a  colorless  or  brownish  liquid,  which  exerts  decided 
local  anesthetic  powers,  but  is  rarely  used  on  account  of  its  irritant 
action. 

Methyl  oxid  is  a  gaseous  or  liquid  substance  which  is  strongly 


THE  ANESTHETIC  EFFECTS  OF  PRESSURE- ANEMIA        6 1 

refrigerant.  Methyl  chlorid  (CH3C1),  the  most  useful  of  this  group 
is  a  powerful  agent;  under  high  pressure  it  is  a  colorless  fluid,  with  a 
boiling-point  of  —  23°C.,  and  has  to  be  kept  in  strong  metal  con- 
tainers. The  rapid  evaporation  of  this  liquid  is  said  to  produce  a 
temperature  of  —  55°C.,  while  ethyl  chlorid  produced  —  35°C. 
Such  powerful  agents  as  methyl  chlorid  have  to  be  used  with  great 
caution,  as  the  intense  cold  generated  may  injure  the  tissues  and 
cause  necrosis;  to  avoid  this  danger  it  has  been  recommended  to 
saturate  tampons  with  the  solution  and  place  them  upon  the  part  to 
be  frozen;  this  lessens  the  intense  cold  produced  by  retarding  evap- 
oration; in  this  way  freezing  is  said  to  occur  in  a  few  minutes,  but 
even  with  this  precaution  damage  may  result  to  the  tissues. 

To  moderate  the  powerful  effect  of  methyl  chlorid  various  com- 
binations with  ethyl  chlorid  and  other  substances  have  been  sug- 
gested; thus  methylil,  which  is  a  proprietary  mixture,  is  a  combina- 
tion of  methyl  and  ethyl  chlorid  with  chloroform. 

The  rapidity  and  intensity  of  the  local  freezing  action  of  any 
of  these  agents,  aside  from  their  power  to  abstract  heat,  depends 
upon  the  vascularity  of  the  part,  and  the  duration  of  its  action  is 
influenced  by  the  same  factors;  in  highly  vascular  tissues  this  action 
is  less  marked  and  of  shorter  duration  than  when  the  opposite  condi- 
tions exist.  In  parts  where  the  circulation  can  be  controlled  a 
much  more  intense  action  is  obtained,  which  is  also  of  much  longer 
duration,  and  this  action  is  further  increased  if  the  part  is  first  ren- 
dered ischemic.  When  used  under  these  conditions  great  care 
is  necessary  to  avoid  permanent  injury  to  the  parts,  resulting  from 
coagulation  of  the  blood  in  the  superficial  vessels  terminating  in 
localized  gangrene. 

The  local  freezing  action  of  all  of  these  sprays  first  causes  an  ex- 
treme degree  of  vasoconstriction,  which  is  followed  by  a  vasodilation 
more  or  less  marked,  depending  upon  the  intensity  and  duration 
of  the  freezing  process;  this  may  persist  as  a  red  hyperemic  spot  at 
the  site  of  application  for  some  time.  According  to  Boeri  and  Sil- 
vestro,  the  sense  of  pain  is  affected  first  and  most  intensely,  tactility 
next,  while  the  pressure  sense  is  affected  least.  The  reaction  of  the 
tissues  from  this  freezing  process  is  not  always  without  pain,  which 
at  times  may  be  considerable  and  is  of  an  aching,  burning  character. 

When  it  is  desired  to  obtain  the  most  intense  action  of  the  cold, 
in  addition  to  the  exsanguination  of  the  part  above  suggested,  it 
is  well  to  remove  all  fat  from  the  skin  by  either  ether  or  benzine. 
On  the  other  hand,  it  may  be  desirable  to  protect  the  parts,  par- 


62  LOCAL   ANESTHESIA 

ticularly  such  tender  tissues  as  the  face,  scrotum,  etc.,  from  a  too 
violent  action  of  the  agent,  by  first  smearing  them  lightly  with 
vaselin,  or,  as  Prosoroff  has  suggested,  by  the  interposition  of  thin 
metal  plates;  something  of  this  kind  should  be  used  particularly 
about  the  eyelids.  These  agents  are  not  suited  for  use  about  the 
anus,  and  when  used  about  the  anal  region  these  parts  should  be 
first  protected  by  tampons  before  applying  the  spray  to  the  sur- 
rounding parts. 

In  using  an  ether  spray  care  is  necessary  about  an  open  fire  or 
near  a  cautery,  but  the  same  danger  does  not  exist  with  ethyl  chlorid, 
which  is  not  inflammable.  However,  none  of  these  agents  are  quite 
satisfactory  when  it  is  intended  to  use  a  cautery  upon  the  parts. 
If  they  are  deeply  frozen,  a  superficial  cauterization  may  be  ac- 
complished; with  such  evanescent  anesthesia  as  is  obtained  with  these 
agents  the  after-burning  will  be  considerable;  it  is,  therefore,  better 
when  cauterization  is  intended  to  use  other  means  of  anesthesia. 

These  freezing  sprays  are  best  suited  to  superficial  minor  opera- 
tions, which  at  most  do  not  involve  more  than  an  incision,  and  may 
have  particular  indications  where  it  is  not  advisable  to  infiltrate  an 
inflamed  or  infected  area  with  local  anesthesia.  Their  especial  claim 
for  usefulness  is  in  the  time  that  is  saved.  They  will  accordingly 
be  found  most  useful  in  opening  boils  or  superficially  situated  ab- 
scesses, and  the  removal  of  foreign  bodies,  such  as  splinters,  etc., 
from  beneath  the  skin.  When  skillfully  used  as  a  continuous  spray 
they  are  also  efficient  in  removing  ingrowing  toe-nails. 

Certain  venturesome  operators  have  even  attempted  major 
operations  by  their  use  alone;  thus,  Dolbeau  has  resected  a  scapula 
practically  without  pain  by  a  continuous  spray,  freezing  as  he  ad- 
vanced, but  it  is  highly  probable  that  such  prolonged  freezing  would 
be  followed 'by  serious  after-consequences,  and  the  same  could  prob- 
ably have  been  done  by  simpler  and  easier  measures. 

Spencer  Wells  attempted  an  ovariotomy  and  succeeded  in  getting 
through  the  abdominal  walls  without  pain,  but  had  to  abandon  the 
attempt  and  resort  to  general  anesthesia  to  complete  the  operation. 

Richardson  and  Greenhalgh  were  more  successful  with  a  Cesarean 
section,  which  they  completed  with  this  means  alone  and  almost  with- 
out pain.  Such  procedures  as  these  are  not  of  practical  clinical  value, 
and  are  not  to  be  recommended;  they  are  principally  of  value  in 
showing  what  can  be  done  under  extreme  conditions  by  skillful  opera- 
tors with  these  agents. 

To  obtain  the  maximum  effect  from  any  of  these  sprays  it  is  neces- 


THE   ANESTHETIC   EFFECTS    OF   PRESSURE-ANEMIA  63 

sary  to  hold  the  tube  just  far  enough  from  the  skin  so  that  evapora- 
tion is  at  its  height  by  the  time  the  spray  strikes  the  skin;  if  held 
too  far  away  much  effect  is  lost,  and  if  too  close  the  liquid  will  run 
down  on  other  parts  or  evaporation  be  delayed. 

Regional  anesthesia,  by  freezing  the  tissues  over  superficial  situ- 
ated nerves,  such  as  the  ulna  at  the  condyle  of  the  humerus,  has  been 
tried,  but  there  are  hardly  any  indications  or  emergencies,  which 
would  arise  to  make  this  method  preferred  over  the  safer,  surer,  and 
more  surgical  use  of  other  measures. 

Ethyl  chlorid  and  other  sprays  are  particularly  useful  in  den- 
tistry; for  this  purpose  certain  mechanical  arrangements  have  been 
devised  with  a  two-pronged  spray,  so  shaped  as  to  spray  both  sides 
of  the  gum  at  the  same  time.  Kiihnen  was  the  first  to  invent  and 
use  such  an  apparatus.  Their  particular  claim  for  merit  in  den- 
tistry is  that  in  inflamed  conditions  of  the  gums  less  injury  is  done 
by  a  freezing  process  than  would  be  the  case  with  infiltration,  which, 
under  such  conditions,  may  be  followed  by  suppuration. 

Many  other  means  and  agents  have  been  used  to  obtain  a  local 
anesthetic  effect  through  the  agency  of  cold.  Dr.  Mellish  has  called 
attention  to  the  fact  that  alcohol  at  —  io°F.  produces  complete 
analgesia,  but  does  not  abolish  tactility. 

Carbon  dioxid  snow  may  also  be  used  for  its  freezing  effect,  but 
is  not  so  easily  handled,  as  it  has  to  be  placed  in  lumps  or  balls  upon 
the  parts  to  be  acted  upon;  it  is  principally  used  in  this  way  for  other 
therapeutic  purposes;  when  so  used,  its  action  can  be  greatly  inten- 
sified by  dropping  ether  upon  it.  The  injection  of  cold  solutions  into 
the  tissues  to  obtain  a  direct  action  of  the  cold  in  this  way  has  been 
tried,  but  such  practices,  to  say  the  least,  are  unsurgical,  highly 
painful,  and  produce  but  a  very  ephemeral  effect,  and  may  be 
followed  by  serious  consequences. 

Cold  intensifies  the  action  of  all  local  anesthetics,  and  is  often  used 
as  an  adjunct  to  local  methods  of  anesthesia  and  will  be  spoken  of  in 
this  connection  elsewhere. 

WATER  ANESTHESIA 

Pure  water  was  first  used  for  its  analgesic  action  by  Potain,  who 
introduced  it  in  1869.  The  term  aquapuncture  was  applied  to  these 
injections,  and  they  were  used  extensively  in  the  treatment  of 
neuralgia.  Mathieu  (1869)  and  Siredey  (1872)  also  describe  this 
procedure. 


64  LOCAL   ANESTHESIA 

This  injection  was  used  only  for  its  therapeutic  effect,  and  it  has 
not  been  recorded  whether  any  analgesia  of  the  overlying  skin  had 
been  observed  to  follow  its  use  or  not;  its  action  was  the  same  as 
that  made  use  of  to-day  for  surgical  purposes.  The  first  use  of 
the  hypodermic  infiltration  of  the  tissues  for  surgical  analgesia  has 
been  credited  to  foreign  surgeons,  particularly  Germans;  this,  how- 
ever, as  far  as  the  literature  can  be  depended  upon,  is  probably  an 
error. 

W.  S.  Halsted,  in  a  letter  published  in  the  New  York  Medical 
Journal,  September  19,  1885,  makes  the  following  statement  regard- 
ing water  anesthesia: 

"i.  The  skin  can  be  completely  anesthetized  to  any  extent  by 
cutaneous  injections  of  water. 

"2.  I  have  at  times  of  late  used  water  instead  of  cocain  in  minor 
operations  requiring  skin  incisions. 

"3.  The  anesthesia  seldom  oversteps  the  boundary  of  the  original 
bloodless  wheal,  but  does  not  always  vanish  just  as  soon  as  hyperemia 
supervenes." 

This  use  of  it  is  again  referred  to  by  Prof.  Halsted  in  a  personal 
communication  to  Dr.  Dawbarn  in  1885  ("Water  as  a  Local  Anes- 
thetic, Its  Discovery  American  and  not  German,"  Med.  Rec.,  1891, 
Dawbarn).  It  was  not,  however,  until  some  years  later  that  this 
method  was  brought  forward  by  our  German  confreres,  and  it  is  to 
them,  notably  Liebreich,  in  his  "Anesthesia  Dolorosa,"  followed 
shortly  by  Schleich  that  credit  is  due  for  the  thorough  application 
and  study  of  the  method. 

Prof.  Bartholow,  in  his  "Materia  Medica,"  as  early  as  1885,  p. 
690,  states  the  following; 

It  is  a  remarkable  circumstance  that  aquapuncture  has  the 
power  to  relieve  pain  in  a  superficial  nerve.  So  decided  is  this  effect 
that  there  are  physicians  who  hold  that  the  curative  effect  of  the 
hypodermic  injection  of  morphin  is  due  not  to  morphin,  but  to  the 
water." 

Since  its  introduction  it  has  been  tried  and  accepted  by  nearly 
all  surgeons  using  local  anesthesia  to  any  extent  that  a  satisfactory 
operative  analgesia  can  be  secured  by  the  injection  of  sterile  water 
alone  into  the  tissues.  Just  how  this  analgesia  is  produced  is  not 
clearly  understood,  but  it  is  probably  due  to  the  imbibition  of  the 
water  by  the  cells  of  the  tissues  causing  them  to  swell  and  thus  inter- 
fere or  prevent  the  transmission  of  painful  impressions.  (See 
chapters  on  Osmosis  and  Diffusion  and  Infiltration.) 


THE    ANESTHETIC    EFFECTS    OF   PRESSURE-ANEMIA  65 

This  method  can  be  most  effectively  demonstrated  in  loose  and 
relaxed  tissues  where  infiltration  can  be  readily  carried  out,  and  is 
less  satisfactory  when  the  tissues  are  compact  or  dense.  The  term 
"anesthesia  dolorosa"  is  most  appropriate  to  this  method,  as  anes- 
thesia is  only  secured  at  the  expense  of  a  certain  amount  of  pain  or 
discomfort  of  a  burning  character ;  this  however,  is  influenced  largely 
by  certain  conditions;  it  is  more  marked  in  dense  tissues,  when  the 
injection  is  rapidly  made  and  when  the  temperature  of  the  injected 
water  varies  from  that  of  the  body;  the  pain,  is  not  severe  and 
is  of  short  duration,  and  is  followed  by  an  analgesia  of  about  ten  to 
fifteen  minutes'  duration.  In  the  hands  of  skillful  operators,  when 
the  injected  water  is  about  body  temperature  and  slowly  and  gently 
infiltrated  with  a  sharp  needle,  little  or  no  discomfort  is  complained 
of.  To  obtain  the  full  analgesic  effect,  it  is  necessary  to  infiltrate 
the  tissues  to  the  point  of  producing  a  glassy  edema,  the  skin  or 
mucous  membrane  must  be  infiltrated  intradermally  and  the  infiltra- 
tion carried  down  the  full  depth  of  the  proposed  incision;  when  this 
is  done  analgesia  is  usually  as  profound  as  after  infiltration  with 
the  weaker  anesthetic  solution,  but  tactility  is  little  or  not  at  all 
affected ;  the  after-pain  or  discomfort  is  about  the  same  as  that  follow- 
ing the  use  of  other  anesthetic  solutions;  although  Gant  claims  that 
the  after-pain  is  less  severe  and  less  prolonged  than  that  following 
other  local  methods.  The  injurious  action  upon  the  tissues  should, 
by  reasoning  along  purely  physical  grounds,  be  greater  than  when 
using  other  anesthetic  solutions,  which  are  more  nearly  isotonic. 
The  injection  of  sterile  water  causes  the  surrounding  cells  to  take  up 
large  quantities  as  well  as  giving  up  a  large  part  of  their  salts,  which 
certainly  should  produce  profound  physical  changes  in  the  cells,  and 
it  would  be  expected  that  certain  reactions  or  even  inflammation 
would  follow  the  physical  readjustment  of  the  tissues.  Gant,  who  is 
a  great  advocate  of  water  anesthesia  in  this  country,  and  employs 
the  method  extensively  for  operations  about  the  anorectal  region, 
denies  any  after-inflammatory  reaction. 

In  the  experience  of  the  writer,  the  experimental  use  of  plain 
water  upon  himself,  as  well  as  a  limited  operative  experience  with  the 
method,  has  failed  to  notice  any  after-pain  or  other  unpleasant  reac- 
tion following  its  use  in  a  very  limited  way.  In  opening  a  furuncle 
upon  my  own  face  water  anesthesia  was  used  for  the  purpose  of  study- 
ing its  action;  the  water  was  injected  at  about  body  temperature, 
and,  when  slowly  injected,  caused  only  a  slight  burning  sensation 
but  when  the  injection  was  made  too  rapidly,  this  burning  sensation 


66  LOCAL   ANESTHESIA 

was  increased,  and  might,  if  used  on  a  sensitive  person,  cause  some 
complaint.  There  was  absolute  analgesia  during  the  incision  and  no 
after-inflammatory  action  was  observed. 

Notwithstanding  its  demonstrated  utility  as  a  practical  means  of 
obtaining  a  surgical  analgesia  its  use  for  any  but  minor  surgical  pro- 
cedures is  hardly  to  be  recommended  on  physiologic  grounds;  as  it  is 
known  that  the  use  of  such  hypotonic  solutions  as  distilled  water 
causes  the  cells  to  absorb  large  quantities  macerating  their  proto- 
plasm and  may  be  followed  by  necrosis. 

Experimentally,  it  has  been  found  that  the  injection  of  distilled 
water  into  dogs,  at  the  ratio  of  10  drams  to  the  pound  of  body 
weight,  is  followed  in  a  short  time  by  the  death  of  the  animals. 

Dr.  Dawbarn,  of  New  York,  after  witnessing  Prof.  Halsted,  in 
1885,  perform  minor  operations  with  pure  water  infiltration,  con- 
ceived the  idea  that  the  analgesia  was  due  to  a  purely  mechanical 
separation  of  the  tissue-cells,  and  that  any  agent  which  could  ac- 
complish this  purpose  would  yield  like  results.  He  accordingly 
undertook  a  series  of  experiments  upon  himself,  injecting  sterile 
air  into  the  tissues  instead  of  water;  although  he  persisted  to  the 
point  of  producing  a  very  decided  degree  of  emphysema,  there  was 
no  diminution  in  the  sensibility  of  the  part. 


CHAPTER  V 
LOCAL  ANESTHETICS 

THE  history  of  the  use  of  local  means  of  analgesia  precedes  that 
of  the  use  of  general  analgesics  or  narcotics.  Many  of  the  older 
agents  or  methods  have  long  since  been  forgotten;  some  few,  such 
as  cold,  in  its  more  improved  use,  fill  an  important  place  in  our 
therapeutics  of  to-day. 

Most  agents  used  for  this  local  anesthetic  action,  except  purely 
physical  means,  such  as  pressure  and  cold,  exert  this  influence  through 
their  toxic  or  paralyzing  effects  upon  the  tissues  and  their  nerve- 
endings.  All  such  agents  when  absorbed  in  sufficient  quantities 
produce  the  same  constitutional  effects,  though  often  associated  with 
other  symptoms  which  may  predominate. 

So  great  was  the  effort  to  find  safe  and  practicable  means  of 
producing  local  anesthesia  that  any  agent  reported  to  possess  these 
properties  was  at  once  put  to  clinical  tests,  and  many  found  a  field 
of  more  or  less  usefulness. 

The  accepted  local  anesthetics  of  to-day,  of  which  cocain  is  the 
type,  exert  this  influence  through  their  paralyzing  action  upon  all 
protoplasm,  and  this  action  is  central  as  well  as  local.  The  con- 
stant effort  to  improve  our  methods  and  produce  an  agent  having 
less  central  toxic  action  while  retaining  its  local  effect  has  lead  to  vast 
improvements,  novocain  representing  the  highest  attainment  in 
this  direction  at  the  present  time,  having  largely  displaced  many  of 
the  older  agents.  How  long  novocain  will  hold  this  place  remains 
to  be  answered  by  future  discoveries. 

The  following  is  a  brief  review  of  some  of  the  many  agents  used 
before  and  since  the  discovery  of  cocain,  for  these  agents  a  more  or 
less  degree  of  local  analgesia  or  anesthesia  had  been  claimed. 

Carbolic  Acid. — The  anesthetic  action  of  topical  applications  of 
pure  carbolic  acid  has  been  long  known,  but  the  escharotic  action 
following  its  use  has  limited  its  employment  to  the  most  superficial 
of  applications  on  external  and  exposed  parts;  its  solutions  when 
injected  into  the  tissues  are  painful,  and,  while  producing  anes- 
thesia, are  likely  to  be  followed  by  tissue  necrosis.  It  has  been  vari- 
ously employed  in  combination  with  other  agents,  as  with  cocain  in 
"cocaine  phenate,"  at  one  time  put  upon  the  market  by  Merck. 

67 


68  LOCAL   ANESTHESIA 

This  was  supposed  to  be  a  distinct  chemical  combination,  but  it  was 
later  determined  to  be  only  a  mixture,  and  to  consist  of  3  parts  of 
cocain  to  i  part  of  carbolic  acid.  It  is  now  but  rarely  used. 

Various  combinations  of  carbolic  acid  and  oil  were  also  sug- 
gested with  or  without  the  addition  of  cocain.  While  the  anesthesia 
produced  by  these  combinations  was  at  times  intense,  the  objec- 
tionable feature  was  the  tendency  of  carbolic  acid  to  cause  tissue 
necrosis,  which  brought  these  mixtures  into  disfavor.  They  are, 
consequently,  at  present  rarely  used  except  by  a  certain  class  of 
practitioners,  who  make  use  of  the  anesthetic  and  escharotic  proper- 
ties of  the  combination  for  the  injection  of  hemorrhoids  and  such 
accessible  growths,  as  they  wish  to  destroy  by  these  measures;  a 
rather  unsurgical  and  often  dangerous  procedure. 

Chloroform  has  been  credited  with  a  certain  degree  of  local  seda- 
tive action  following  its  injection  within  the  tissues.  Eulenburg, 
in  1867,  recommended  it  for  this  purpose.  Its  anesthetic  action 
is  very  slight  and  is  preceded  by  considerable  burning  pain. 

Methoxycaff ein  is  a  white  amorphous  or  crystalline  powder,  used 
as  a  local  anesthetic  and  antineuralgic.  It  has  been  recommended 
for  hypodermic  use  in  doses  of  about  4  gr.,  given  in  the  neighborhood 
of  the  nerve  in  neuralgic  conditions. 

Alcohol. — More  recently  (1903)  alcohol  had  been  brought  for- 
ward by  Schlosser  as  a  highly  valuable  agent  for  destroying  the 
sensibility  of  purely  sensory  nerves  when  used  as  an  intraneural 
or  paraneural  injection.  Its  action  is  due  to  the  resulting  inflamma- 
tion and  fibrous  changes  which  it  induces  in  the  tissues,  blocking  or 
destroying  the  nerve  at  this  point.  It  was  intended  originally  for  use 
in  neuralgias,  especially  in  the  trigeminus,  and  more  recently  for  use 
as  a  paraneural  injection  to  the  superior  laryngeal  as  a  means  of 
relieving  pain  in  tuberculosis  and  cancer  of  the  larynx.  Particularly 
in  the  trigeminus  is  its  action  of  considerable  duration,  often  pre- 
venting the  return  of  pain  for  periods  of  six  to  eighteen  months, 
when,  as  regeneration  slowly  recurs,  the  pain  usually  returns,  pro- 
vided the  original  causative  conditions  still  persist. 

Reclus  at  one  time,  following  the  suggestion  of  Billon,  used  20 
parts  of  90  per  cent,  alcohol  in  his  local  anesthetic  mixtures  (stovain 
was  the  agent  used) ;  this  was  done  with  the  view  of  prolonging  and 
intensifying  the  action  of  the  stovain.  (See  latter  part  of  this 
chapter.) 

Dr.  Hellish  recorded  the  observation  that  a  finger  immersed  in 
alcohol  at  —  io°F.  produced  analgesia,  but  did  not  destroy  tactility; 


LOCAL   ANESTHETICS  69 

here  we  are  probably  dealing  entirely  with  the  effects  of  cold.  This 
use  of  alcohol,  particularly  by  Reclus  in  solutions  intended  for  infil- 
tration, prompted  the  author  to  undertake  some  experiments  upon 
himself,  with  a  view  of  determining  its  action  upon  some  superficial 
part  where  observations  could  be  constantly  made.  It  was  intended, 
should  the  knowledge  gained  be  likely  to  prove  useful,  to  make  a  more 
extensive  series  of  tests,  but  in  view  of  the  results  only  10,  2or  and  50 
per  cent,  strengths  were  used  in  various  ways. 

Ten  per  cent,  solutions  in  distilled  water,  when  injected  intra- 
dermally,  caused  a  sharp  burning  pain  for  about  half  a  minute,  skin 
turning  slightly  pale,  later  becoming  hyperemic.  Sensibility  slightly 
dulled  over  area,  but  would  not  permit  a  painless  incision — normal 
sensibility  returned  in  about  two  hours,  but  area  remained  slightly 
hyperemic  for  several  days. 

Twenty  per  cent,  solutions  in  distilled  water  gave  nearly  similar, 
though  slightly  more  pronounced,  results.  As  this  was  the  strength 
used  in  his  anesthetic  solutions  by  Reclus,  it  was  accordingly  com- 
bined with  local  anesthetics;  infiltration  of  this  mixture  caused, 
when  injected,  a  burning  pain,  nearly  as  intense  as  when  used  in  dis- 
tilled water  alone,  but  of  shorter  duration  (only  a  few  seconds) ;  this 
gave  place  to  anesthesia;  the  anesthesia,  however,  seemed  no  more 
intense  or  prolonged  than  when  the  same  solution  was  used  without 
alcohol,  and  was  followed  by  hyperemia  of  about  two  days'  duration. 

Normal  salt  solution  was  then  used  as  a  diluting  agent,  but  did 
not  seem  to  influence  the  reaction  to  any  noticeable  degree;  both 
were  painful  and  produced  hyperemia. 

Alcohol,  50  per  cent.;  distilled  water,  50  per  cent.  (20  minims), 
10.50  P.  M.  Injection  intradermal  caused  a  very  short  burning  pain, 
lasting  about  one  minute,  produced  a  wheal  about  the  size  of  a  5-cent 
piece,  surrounded  by  an  injected  area  about  as  large  as  a  dollar; 
center  of  wheal  at  point  of  needle  stick  is  perfectly  white  and  slightly 
depressed,  and  surrounded  by  a  bright  red  circle.  If  wheal  is  not 
disturbed  by  manipulation  no  sensation  is  experienced,  but  when 
manipulated  with  the  fingers  caused  a  slight  return  of  burning  sensa- 
tion of  short  duration.  It  continues  to  react  in  this  manner  for 
eighteen  minutes. 

The  depressed  white  area  became  immediately  anesthetic,  but 
remainder  of  the  wheal  only  slightly  less  sensitive  than  the  sur- 
rounding healthy  tissue. 

In  thirty  minutes  the  entire  wheal,  except  the  white  center,  has 
regained  normal  sensibility;  the  center  looks  as  if  the  skin  has  been 


70  LOCAL    ANESTHESIA 

completely  destroyed.  After  eight  hours  wheal  has  entirely  disap- 
peared, though  tissues  at  that  point  are  slightly  thickened.  The 
central  white  spot  is  still  absolutely  dead  to  feeling,  but  is  no  longer 
depressed  below  surrounding  skin  and  the  red  circle  has  disappeared. 
After  twelve  hours  slight  return  of  red  zone  around  central  white  area. 
Repeated  observations  during  next  ten  days  showed  a  gradual 
enlargement  of  red  zone,  which  became  quite  inflamed  and  about  3^ 
inch  in  diameter.  Central  white  area  shows  signs  of  gradually 
sloughing  out.  Observations  discontinued  after  ten  days,  with  the 
conclusion  that  its  anesthetic  action  depends  entirely  upon  its 
destructive  influence  upon  the  tissues,  and  may  in  the  use  of  strong 
solutions  be  followed  by  necrosis. 

That  this  does  not  occur  in  deep  facial  injections  is  probably  due 
to  the  high  vascularity  and  nutrition  of  the  parts. 

J.  L.  Corning  has  used  alcohol  and  chloroform  subcutaneously 
in  studying  their  anesthetic  effect,  and  found  that  they  produced 
considerable  pain,  but  no  anesthesia. 

"These  observations  tend  to  dissipate  the  expectations  of 
Nunnely,  of  Leeds,  who  declared  that  by  exposure  to  the  vapor  of 
chloroform  he  had  been  able  to  cause  sufficient  insensibility  in  a  finger 
to  render  the  performance  of  a  surgical  operation  painless." 

Morphin. — A  solution  of  4  per  cent.,  which  has  the  same  freezing- 
point  as  the  blood-serum  when  injected  into  the  tissues,  produces 
severe  burning,  then  hyperesthesia,  followed  by  analgesia.  As  the 
solution  is  diluted  it  rapidly  loses  its  analgesic  effect.  A  solution  of 
o.i  per  cent,  produces  a  well-marked  wheal,  which  itches  and  burns 
like  the  bite  of  an  insect,  but  not  analgesia.  This  local  irritating 
influence  is  felt  with  solution  as  weak  as  i :  100,000  parts  of  water. 

Bromids  of  sodium  and  potassium,  when  in  solutions  injected 
within  the  tissues,  are  said  to  produce  a  certain  degree  of  analgesia, 
but  are  preceded  by  an  intense  degree  of  irritation. 

Chloral  has  also  been  credited  with  similar  action. 

Brucin  in  5  per  cent,  solution  produces  a  limited  degree  of  local 
anesthesia. 

Antipyrin  is  an  agent  which  possesses  mild  but  sufficiently  well- 
marked  anesthetic,  antiseptic,  and  hemostatic  properties  to  have 
claimed  for  it  a  decided  field  of  usefulness  in  the  past  before  the 
introduction  of  better  and  more  active  agents,  and  occasionally  is  still 
employed. 

Cycloform  is  isobutyl  paramidobenzoic  acid  and  possesses  some 
local  anesthetic  properties. 


LOCAL   ANESTHETICS  71 

Many  agents  like  thymol,  menthol,  guaiacol,  ichthyol,  monotal, 
spirosal,  etc.,  exhibit  local  sedative  or  analgesic  action  when  topically 
applied,  and  are  useful  over  inflamed  and  painful  parts,  but  are  not  of 
especial  interest  to  us  here. 

Similar  sedative  or  varying  degrees  of  anesthetic  action  have  been 
claimed  for  many  other  drugs,  such  as  the  digitalis  group — digitalin, 
strophanthin,  convallarin,  helleborin,  adonidin,  and  others  too 
numerous  to  mention  and  of  no  practical  value. 

There  are  many  combinations  of  anesthetic  agents  which  have 
been  upon  the  market  under  various  trade  names;  thus,  andolin  con- 
tains beta-eucain,  stovain,  and  adrenalin;  eusemin,  a  mixture  of 
cocain  and  adrenalin;  and  codrenin,  a  mixture  of  cocain,  chloretonej 
and  adrenalin;  and  many  others. 

Electric  anesthesia  is  also  a  medical  possibility,  both  for  general 
anesthesia  as  well  as  for  local  use,  where  the  general  consciousness  is 
not  disturbed;  it  may  promise  much  for  the  future. 

Since  the  advent  of  cocain  many  local  anesthetics  have  been  in- 
troduced for  which  various  claims  have  been  made;  some  have  ful- 
filled these  claims,  others  have  not;  some,  by  virtue  of  their  merits  in 
general  surgery  or  some  special  field,  will  probably  always  be  re- 
tained in  our  armamentarium  and  find  a  more  or  less  limited  use 
according  to  their  special  indications,  while  many,  after  having  been 
put  through  the  test  of  practical  clinical  application  and  found  want- 
ing, will  be  dropped  and  likely  soon  forgotten. 

In  spite  of  the  many  new  agents  introduced,  and  the  many  ad- 
vances made  in  synthetic  chemistry,  cocain  still  remains  the  standard 
and  most  universally  employed  anesthetic,  although  it  should  now  be 
entirely  superseded  by  novocain  for  all  general  surgical  purposes. 

In  judging  the  comparative  merit  of  any  new  claimant  for  surgical 
favor  in  the  field  of  local  or  regional  anesthesia,  we  must  ask  our- 
selves at  least  three  questions: 

1.  What  are  the  requirements  that  we  must  demand  of  the 
ideal  local  analgesic  or  anesthetic,  utilizing  these  requirements  as  the 
basis  or  standard  of  comparison? 

2.  What  are  the  claims  made  for  the  new  anesthetic? 

3.  To  what  extent  does  experience  confirm  these  claims? 

To  answer  these  questions  we  would  require:  that  the  anesthetic 
should  be  efficient  in  producing  a  durable,  diffusible,  and  maximum 
analgesic  effect;  that  it  be  non-toxic  to  the  organism  and  produce 
the  minimum  of  local  tissue  disturbance.  It  should  be  absolutely 


72  LOCAL   ANESTHESIA 

sterilizable   by   heat;    soluble;    compatible    with    adrenalin;    com- 
mercially accessible  at  reasonable  cost. 

After  considering  the  above,  and  reading  the  description  of  the 
following  anesthetics  and  the  critical  and  comparative  review  at  the 
end  of  this  chapter,  it  is  found  that  novocain  is  the  only  agent  which 
comes  nearest  filling  all  these  requirements ;  and  anesthesin,  if  put  to 
equally  rigorous  tests  for  purely  topical  applications,  will  be  found 
equally  satisfactory  in  this  particular  field  of  usefulness. 

COCAIN 

Cocain  (methyl  benzoylecgonin) ,  C5Hi7(CH3)NCH(OCOCH5)- 
(CH2COOCH3). 

The  alkaloid  and  hydrochlorate  are  the  only  two  preparations 
official  in  the  United  States  and  British  Pharmacopeias;  the  oleate 
and  ointment  are  mixtures. 

Many  salts  of  cocain  have  at  times  been  put  upon  the  market 
by  the  manufacturers  in  the  hope  of  producing  a  better  preparation 
than  the  hydrochlorate,  but  none  have  so  far  fulfilled  these  claims 
except  for  special  purposes.  Most  of  these  preparations  are  true 
salts,  some  are  double  salts,  and  a  few  are  found  to  be  only  mixtures. 

Cocain  aluminum  citrate  and  cocain  aluminum  sulphate  are  as- 
tringent preparations,  and  are  intended  for  topical  applications;  the 
borate  has  antiseptic  properties,  and  has  been  particularly  advocated 
as  an  eye-wash;  its  hypodermic  use  is  at  times  irritating. 

Cocain  cantharidate  has  been  recommended  for  hypodermic  use 
in  certain  forms  of  nasal  catarrh  and  for  tubercular  conditions  of 
the  upper  air-passages  and  larynx;  its  use  causes  a  mild  inflammation 
which,  through  the  increased  blood-supply  to  the  parts,  had  been 
hoped  to  favor  curative  processes  in  these  lesions;  it  is  not  often 
used;  the  carbolate,  as  mentioned  elsewhere,  is  a  mixture;  the  lac- 
tate  has  been  recommended  as  a  sedative  application  and  injection 
in  cystitis;  the  nitrate  has  a  particular  field  of  usefulness  in  gonor- 
rheal  inflammations  and  for  combination  with  some  of  the  many 
silver  salts  used  in  this  infection;  the  phosphate  is  a  useful  preparation, 
but  is  not  very  soluble  and  has  little  to  recommend  it;  cocain  saccha- 
rate  has  been  suggested  for  topical  applications  and  for  use  in  throat 
and  mouth  operations;  the  salicylate  was  at  one  time  advocated  for 
use  in  asthma;  it  is  now  rarely  used,  its  continued  employment  may 
lead  to  a  habit;  the  stearate  is  a  mixture  used  for  topical  applications, 
for  suppositories  and  ointments,  but  is  now  rarely  used. 


LOCAL    ANESTHETICS  73 

The  alkaloid  was  first  isolated  by  Gardeka  in  1855,  who  named  it 
erythroxylin,  but  renamed  slightly  later  by  Niemann,  who  made  a 
much  fuller  investigation  concerning  its  action.  It  began  to  be  used 
in  medicine  as  early  as  1880  in  a  very  limited  way,  although  its  dilat- 
ing effect  upon  the  pupil  had  long  been  known.  It  was  not,  how- 
ever, until  1884,  when  brought  forward  by  Roller,  that  its  true  value 
began  to  be  known,  and  it  came  very  shortly  into  general  use.  This 
immediate  increased  demand  for  the  drug  far  exceeded  the  limited 
facilities  for  its  manufacture,  and  had  the  effect  of  markedly  increas- 
ing the  price,  which  is  reported  to  have  risen  as  high  as  $3  per  grain; 
as  the  manufacturing  facilities  developed  this  price  rapidly  fell  in  a 
few  years  to  one  cent  per  grain,  and  has  since  been  further  decreased 
by  improvements  in  the  method  of  manufacture  as  well  as  a  steadi- 
ness of  the  supply.  During  the  early  days  of  its  use  the  methods  of 
manufacture  and  purification  were  very  imperfect,  and  led  to  its 
admixture  with  many  impurities,  giving  rise  often  to  serious  acci- 
dents when  used  about  the  eye  and  to  a  misinterpretation  of  its  nor- 
mal action.  The  synthetic  preparation  of  the  drug  has  been  another 
means  of  reducing  the  cost  of  manufacture,  as  well  as  having  led  to 
the  discovery  of  many  valuable  synergistic  drugs  which  have  proved 
highly  valuable. 

Tests. — The  following  tests  have  been  offered  as  a  means  of  de- 
termining its  purity: 

Maclagan  's:  Dissolve  i  grain  of  cocain  hydrochlorate  in  2  ounces 
of  distilled  water,  to  which  add  i  or  2  drops  of  ammonia  solution; 
after  stirring  for  a  few  minutes,  if  free  from  amorphous  cocain,  cocain 
hydrate  will  separate  from  the  solution  in  crystalline  form  and  settle 
at  the  bottom,  leaving  the  supernatant  solution  clear  and  free  from 
opalescence,  any  cloudiness  indicating  the  presence  of  amorphous 
cocain. 

Gartier  's:  Mix  i  drop  of  a  2  per  cent,  solution  of  permanganate  of 
potassium  with  a  solution  of  cocain  hydrochlorate  (2  cgm.  to  0.5  gm.). 
The  resulting  fluid  must  assume  a  red  color  and  remain  transparent. 
To  this  solution  add  drop  by  drop  more  of  the  permanganate  solu- 
tion, when  there  should  appear  a  red  precipitate  of  permanganate  of 
cocain;  this  should  become  brown  only  after  heating  and  without 
giving  off  an  odor  of  bitter  almonds.  If  the  addition  of  i  drop  of  the 
permanganate  solution  produces  a  brown  color  or  brown  precipitate, 
or  when  on  heating  the  mixture  there  is  produced  an  odor  of  bitter 
almonds,  the  preparation  is  impure  and  unfit  to  use. 

In  discussing  the  physiologic  action  of  the  local  anesthetics — 


74  LOCAL   ANESTHESIA 

cocain  and  its  congeners — we  will  describe  in  full  only  cocain,  for 
what  applies  to  cocain  is  equally  applicable  to  almost  the  entire 
group;  any  differences  that  exist  are  slight  and  vary  in  degree  not  in 
kind. 

Where  these  differences  are  of  consequence  attention  will  be 
called  to  them. 

Physiologic  Action. — Cocain  exercises  a  universal  action  on  all 
living  protoplasm,  first  stimulating  and  then  paralyzing  it;  this  action 
applies  to  plant  as  well  as  animal  protoplasm. 

Locally  applied  cocain  acts  as  a  very  decided  anesthetic,  as  first 
brought  out  by  Moreno.  Y.  Maiz,  in  1862,  and  later  by  Von  Anrep, 
in  1880. 

The  soluble  salts  of  cocain  are  absorbed  with  great  rapidity; 
they  pass  with  the  greatest  facility  through  nearly  all  mucous  mem- 
branes, and  are  taken  up  with  an  almost  equal  rapidity  from  de- 
nuded surfaces,  but  are  not  absorbed  from  the  intact  skin.  The 
above  fact  explains  the  large  number  of  cases  of  serious  poisoning 
which  have  resulted  from  its  use  on  mucous  surfaces. 

Extensive  researches,  undertaken  to  study  the  action  of  cocain 
upon  the  vital  manifestations  of  various  kinds  of  cells  of  animal 
life,  was  made  by  P.  Albertoni.  According  to  the  concentration  of 
the  solution  and  the  duration  of  its  action,  it  either  stimulates  or 
paralyzes  all  cells  in  their  functional  activities.  A  0.25  per  cent,  solu- 
tion applied  to  the  palate  of  a  frog  stimulates  markedly  the  activity 
of  the  ciliated  epithelium,  so  that  particles  of  colored  dust  are  moved 
along  at  four  times  their  normal  rate,  while  2  per  cent,  solutions  so 
paralyze  this  action  that  it  amounts  to  one-fourth  or  one-sixth  the 
normal  rate  of  movements.  Similar  experiments  were  conducted 
upon  other  kind  of  cells  or  low  animal  life,  such  as  grubs,  spermato- 
zoids,  and  the  large  blood-cells  of  some  animals,  as  well  as  the  white 
blood-cells  of  man,  all  showed  a  similar  action,  being  stimulated  by 
weak  solutions  when  acting  for  a  short  time,  later  being  paralyzed. 
Muscle-fiber,  when  similarly  treated,  fails  to  respond  either  to  nerve 
or  electric  stimulation.  A  peculiar  action  of  cocain  upon  the  livers 
of  mice  was  brought  out  by  the  studies  of  Ehrlich  who  fed  mice  food 
containing  a  small  quantity  of  cocain,  which  killed  them  after  a  few 
days ;  examination  showed  their  livers  increased  in  volume  and  look- 
ing much  like  stuffed  goose  livers.  Microscopic  examination  showed 
a  vacuolar  degeneration  of  the  cells  with  small  fragments  of  proto- 
plasm about  the  nucleus;  the  blood-vessels  showed  fatty  degeneration; 
the  connective  tissue  was  undergoing  fatty  degeneration  with  points 


LOCAL    ANESTHETICS  75 

of  coagulation  necrosis.  No  glycogen  was  found  in  the  entire  livers. 
Its  action  upon  the  nerve- tissues  cannot,  therefore,  be  strictly  re- 
garded as  of  a  specific  kind,  as  it  exercises  this  same  action  upon 
protoplasm  generally,  although  its  action  upon  nerve-tissue  may  be 
of  a  more  marked  degree,  as  manifested  upon  the  end-organs  of  sen- 
sory nerves  or  upon  the  conductivity  of  their  trunks  when  injected 
intraneurally.  This  constitutes  one  of  the  most  marked  and  striking 
properties  of  cocain,  and  enables  it  to  claim  the  high  position  which 
it  holds  as  a  therapeutic  agent. 

The  well-known  vasoconstrictor  action  of  cocain,  when  brought 
in  contact  with  the  vessel  walls  by  direct  application  or  injection  into 
the  tissues,  can  only  be  expained  by  a  direct  action  upon  the  smooth 
muscle-fibers  within  the  vessel  walls.  This  action  is  also  seen,  but  to 
a  less  degree,  when  the  drug  is  given  constitutionally,  when  it  is 
seen  to  raise  the  blood-pressure,  but  in  large  doses  this  influence 
upon  the  vessels  is  overshadowed  by  the  greater  powers  of  the  drug. 
In  the  early  days  of  its  use  the  anesthetic  action  of  the  drug  was 
erroneously  attributed  to  the  ischemia  that  its  injection  caused,  as  it 
was  known  then  that  ischemic  tissues  were  less  sensitive  than  when 
in  a  normal  state.  It  may  be  possible  that  the  anesthetic  influence 
is  slightly  affected  by  this  ischemia,  but  this  action  must  be  very 
slight,  and  it  is  also  further  disproved  by  the  fact  that  since  the 
introduction  of  cocain  other  anesthetic  agents  have  been  discov- 
ered which  exert  little  or  no  influence  upon  the  vascularity  of  the 
part,  and  some  even  producing  vasodilation,  yet  with  marked  anes- 
thetic action. 

If  the  sequence  of  the  phenomena  following  the  local  application 
of  cocain  (say  to  the  cornea)  are  closely  observed  it  will  be  found 
that  the  anesthesia  precedes  the  anemia  by  a  short  interval  of  time. 

As  demonstrated  by  Mosso  and  amply  confirmed  by  others,  as 
well  as  by  daily  clinical  observation,  cocain  locally  applied  suspends 
the  activity  of  motor  nerves,  although  sensory  nerves  are  first  and 
more  decidedly  influenced.  Applied  to  the  nerves  of  special  sense, 
where  these  nerves  are  accessible  for  experimentation,  it  has  caused 
them  to  lose  their  particular  function,  sight,  smell,  or  taste  being 
lost  during  the  action  of  this  agent.  Tumass  has  been  able  to  demon- 
strate that  it  exercises  this  same  influence  when  applied  to  the  cere- 
bral cortex.  The  motor  areas  of  dogs  were  exposed  by  trephining, 
then  cocainized,  using  solutions  up  to  4  per  cent,  strength;  after 
these  applications  it  was  found  that  the  stimulation  of  these  areas 
barely  produced  any  response;  the  full  effect  of  this  action  lasted 


76  LOCAL   ANESTHESIA 

for  fifteen  minutes,  and  required  forty-five  minutes  to  entirely 
disappear. 

Alms  also  experimented  by  injecting  it  into  the  iliac  artery  of  a 
frog,  in  this  way  carrying  it  to  the  entire  distribution  of  this  vessel 
in  the  lower  limb,  bringing  about  complete  paralysis  of  the  entire 
limb.  This  was  the  first  attempt  at  arterial  anesthesia.  (See  chap- 
ter on  this  subject.) 

It  is  generally  stated  by  all  observers  that  after  large  doses  injected 
into  the  general  circulation  the  sensory  nerves  are  finally  paralyzed, 
but  that  doses  not  dangerous  to  life  have  very  little  effect  upon  the 
general  sensibility.  This  statement  may,  however,  prove  only  par- 
tially correct,  as  in  this  connection  we  would  like  to  call  attention 
to  the  experiments  by  Kast  and  Meltzer,  discussed  in  the  opening 
part  of  the  chapter  on  Abdominal  Surgery,  and  to  its  general  anes- 
thetic action,  as  demonstrated  by  Ritter  and  Harrison;  also  to  the 
observation  by  Ott,  that  in  a  certain  stage  of  cocain-poisoning  irrita- 
tion of  the  central  end  of  the  cut  sciatic  causes  no  response,  while 
irritation  of  the  distal  end  excites  muscular  action. 

Central  Nervous  System. — The  higher  centers  are  first  stimu- 
lated, making  ideas  flow  freer;  laughing,  singing,  or  loquacity  are  also 
usually  produced,  associated  with  a  feeling  of  joy,  happiness,  or  buoy- 
ancy, which  are  the  usual  causes  which  encourage  addiction  to  this 
drug;  these  sensations  are  followed  by  mental  hebetude,  dullness,  or  a 
sense  of  fatigue.  Respiration  is  always  stimulated,  large  doses  pro- 
ducing dyspneic  breathing,  increasing  to  tetanic  convulsions  of  the 
respiratory  muscles  followed  by  paralysis  in  fatal  doses. 

According  to  Dodd,  very  distinct  histologic  changes  can  be  dem- 
onstrated in  the  nerve-centers  after  poisoning  and  that  these  lesions 
are  most  marked  in  the  cerebral  cortex.  While  Verebily  and  Hor- 
vaith  have  been  able  to  demonstrate  nearly  similar  changes  in  nerve- 
tissue  following  its  local  action.  As  ordinarily  used  its  action  must 
be  of  temporary  effect.  Of  the  many  thousand  cases  in  which  cocain 
has  been  used  there  are  comparatively  very  few,  and  most  of  these 
spinal  puncture  cases,  in  which  there  has  been  any  serious  results  or 
permanent  changes  following  its  use.  It  is  most  likely  that  in  many 
of  these  cases  impure  or  non-sterile  solutions  were  used  or  the  technic 
faulty. 

The  action  of  cocain  upon  the  heart  and  vascular  system  is  rather 
complicated,  and  many  points  regarding  its  action  here  are  far  from 
settled.  However,  it  may  be  fairly  safely  stated  that  small  or  me- 
dium doses  stimulate  the  force  and  frequency  of  the  heart  action  and 


LOCAL  ANESTHETICS  77 

raise  the  arterial  tension  by  contracting  the  peripheral  arterioles. 
When  a  solution  of  cocain  is  applied  to  the  eye  there  occurs  first  a 
contraction  of  the  pupil  followed  by  a  dilatation  in  a  few  minutes. 
This  initial  contraction  is  no  doubt  reflex,  the  result  of  mechanical 
irritation,  or  due  to  the  acid  reaction  of  the  solution.  With  medium 
strength  solution  (4  per  cent.)  the  maximum  dilatation  is  reached  in 
an  hour,  and  begins  to  decline  by  the  end  of  the  second  hour,  requir- 
ing from  twelve  to  twenty-fours  to  return  to  normal.  The  dilated 
pupil  is  slightly  responsive  to  light  and  to  accommodation;  the  dilata- 
tion can  be  increased  by  atropin  and  very  rapidly  overcome  by  eserin. 
This  mydriasis  is  due  to  a  peripheral  influence,  and  is  the  result  of 
stimulation  of  the  sympathetic  nerve-endings,  for  when  this  nerve 
is  first  divided  in  animals  and  the  injection  then  made  these  symptoms 
do  not  appear.  Cocain  is  capable  of  producing  a  very  decided  rise 
in  temperature,  sometimes  to  as  much  as  8°F.  in  cases  of  poisoning; 
as  reaction  takes  place  this  is  followed  by  a  fall  before  death.  Reich- 
ert,  in  a  series  of  experiments,  has  been  able  to  determine  that  this 
rise  was  due  to  a  stimulation  of  the  thermogenic  centers  in  the  cau- 
date nucleus,  as  well  as  to  motor  excitement  the  result  of  stimulation 
of  the  motor  centers.  Considerable  variation  has  been  encountered 
by  different  investigators  regarding  the  renal  secretory  function; 
however,  it  is  generally  conceded  that  cocain  markedly  lessens  the 
elimination  of  urea,  and  single  large  doses  have  produced  an  anuria 
sufficiently  prolonged  to  bring  on  uremic  symptoms. 

The  secretion  of  the  saliva  and  perspiration  is  lessened  by  its 
local  or  constitutional  action,  due  to  its  influence  in  constricting  the 
peripheral  circulation. 

Intestinal  peristalsis  is  increased  by  moderate  doses,  large  does 
paralyzing  the  intestines  and  rendering  them  hyperemic.  The  ulti- 
mate fate  of  cocain  within  the  body  is  at  present  uncertain;  when 
large  doses  have  been  used  a  small  quantity,  about  5  per  cent.,  has 
been  recovered  from  the  urine,  but  it  is  no  doubt  very  largely  de- 
stroyed in  the  body  and  broken  up  into  its  molecular  constituents. 

EUCAIN 

The  discovery  of  eucain  was  the  first  decided  advance  in  the  field 
of  synthetic  chemistry  to  crown  the  efforts  of  the  many  investiga- 
tors laboring  to  discover  a  less  toxic  agent  than  cocain. 

This,  like  other  anesthetics  to  be  discovered  later,  is  a  benzoyl 
derivative.  Alpha-eucain  or  eucain  a  was  the  first  discovered.  This 
however,  was  found  to  be  too  irritant  and  did  not  meet  with  much 


78  LOCAL   ANESTHESIA 

favor.  Efforts  on  the  part  of  synthetic  chemists  (Vinci,  1897)  soon 
led  to  the  discovery  of  eucain  b,  or  beta-eucain,  which  eliminated  the 
irritant  qualities  and  reduced  the  toxicity.  Eucain  a  was  soon  en- 
tirely displaced  and  is  now  no  longer  manufactured.  All  the  eucain 
to  be  obtained  is  now  of  the  beta  kind;  this  is  chemically  benzoyl- 
transvinyldiaceton-alkamin  and  is  closely  related  to  tropacocain. 

This  free  base  of  beta-eucain  is  almost  insoluble  in  water,  but 
its  acid  salts  (hydrochlorate)  are  fairly  soluble  3.5  per  cent.  This 
limited  solubility  is  a  decided  disadvantage  and  led  to  the  intro- 
duction of  eucain  lactate,  which  is  soluble  to  22  per  cent,  and  slightly 
less  toxic,  due  to  its  containing  a  slightly  lesser  quantity  of  eucain, 
100  parts,  compared  to  hydrochlorate,  119.  The  lactate  is  a  white 
hygroscopic  powder  of  decidedly  bitter  taste. 

The  various  degrees  of  solubility  of  the  two  salts  is  given  as  fol- 
lows at  ordinary  temperature: 

Hydrochlorate  Lactate 

In  water 3.5  per  cent  22  per  cent. 

In  alcohol 3.5  per  cent.  1 1  per  cent. 

In  chloroform 15.0  per  cent.  20  per  cent. 

In  glycerin 2.0  per  cent.  5  per  cent. 

The  solubility  of  the  hydrochlorate  is  slightly  increased  by  warm- 
ing, and,  as  it  does  not  precipitate  immediately,  increased  strengths 
can  be  used  in  warm  solutions.  Extensive  chemical  experience  with 
this  drug  proves  that  when  injected  hypodermically  for  surgical  pur- 
poses it  is  practically  non-irritant,  but  produces  a  slight  vasodilata- 
tion.  Compared  with  cocain  it  is  slightly  weaker  in  action,  1.5  per 
cent,  solutions  equaling  in  intensity  and  duration  the  action  of  a  i 
per  cent,  solution  of  cocain. 

Regarding  its  toxicity,  a  point  on  which  its  claims  for  preference 
largely  depend,  investigators  are  not  all  of  one  opinion.  Vinci  and 
many  others  claim  it  to  be  three  to  five  times  less  toxic  than  cocain, 
and  this  would  seem  to  be  borne  out  by  the  extensive  clinical  tests 
to  which  the  drug  has  been  submitted,  in  which  few  if  any  cases  of 
poisoning  have  been  reported.  However,  the  careful  investigations 
of  Piquand  and  Dreyfus  (see  latter  part  of  this  chapter  on  the  com- 
parative study  of  the  different  anesthetic  agents)  give  beta-eucain  a 
toxicity  very  slightly  less  than  cocain.  In  this  the  author  does  not 
agree;  for  after  an  extended  use  of  this  agent  in  many  extensive 
major  operations  in  which  6,  8  and  10  gr.  of  this  agent  has  been  used 
in  weak  solution  no  unpleasant  effects  have  been  observed.  Further 
points  in  the  action  of  eucain  are  that  it  is  slightly  slower  in  action 


LOCAL   ANESTHETICS  79 

and  slightly  less  diffusible  than  cocain.  Investigations  seem  to 
clearly  prove  that  it  possesses  well-marked  but  slight  antiseptic 
action,  and  to  possess  the  particularly  desirable  quality  of  being 
capable  of  being  boiled  without  effecting  its  efficiency,  and  its  solu- 
tions may  be  kept  for  considerable  time  without  suffering  deteriora- 
tion. This  agent,  while  possessing  many  advantages  over  cocain,  was 
yet  far  from  proving  thoroughly  satisfactory  to  the  earlier  operators, 
largely  due  to  the  resulting  hyperemia,  which  frequently  gave  rise  to 
troublesome  after-hemorrhage;  this  was  particularly  the  case  in 
dental  surgery.  After  the  introduction  of  adrenalin  in  1900  this 
disadvantage  was  practically  entirely  overcome,  and  the  agent  came 
into  more  extended  and  general  use. 

Following  the  advent  of  adrenalin,  the  advantage  of  a  combina- 
tion with  eucain  was  quickly  recognized  by  the  pioneer  workers  in 
the  field  of  local  anesthesia,  notably  Braun,  Matas,  and  Barker,  who 
utilized  solutions  of  eucain  and  adrenalin  for  the  performance  of  an 
extensive  range  of  major  surgical  procedures,  Matas  devising  an 
ingenious  infiltrating  apparatus  for  edematization  of  the  operative 
field. 

The  following  solution,  recommended  by  Braun,  became  very 
popular: 

Beta-eucain 0.2 

NaCl 0.8 

Aqua 100.  o 

This  solution,  capable  of  boiling,  could  always  be  rendered  thor- 
oughly sterile.  Another  advantage  being  that  the  solution  could  be 
kept  considerable  time  without  change.  The  adrenalin  was  always 
added  to  the  solution  just  before  use,  estimating  the  total  quantity 
likely  to  be  used,  and  adding  to  this  the  necessary  amount  of 
adrenalin. 

Barker's  solution  was  very  similar  to  that  of  Braun's  but  both 
have  the  disadvantage  of  being  too  weak  for  satisfactory  use  for 
anesthetizing  the  skin,  unless  it  is  thoroughly  edematized  also  for 
blocking  large  nerve- trunks;  for  these  last-mentioned  purposes  it  is 
better  to  employ  solutions  slightly  stronger  (about  0.4  per  cent.) , 
but  for  infiltration  of  all  subcutaneous  tissues  the  Braun  solution  is 
found  thoroughly  satisfactory.  It  is  necessary,  for  a  delay  of  ten  or 
fifteen  minutes  after  the  infiltration  before  beginning  the  operation, 
this  allows  the  solution  ample  time  to  thoroughly  saturate  the  tissues 
and  exert  its  maximum  anesthetic  effect. 

In  special  fields  of  work  eucain  has  proved  highly  satisfactory, 


80  LOCAL   ANESTHESIA 

more  particularly  in  the  nose,  although  here  it  has  not  been  univer- 
sally adopted,  and  it  has  never  seriously  threatened  cocain  in  ophthal- 
mology, though  possessing  some  few  advantages  here. 

In  the  nose  the  ischemia  produced  by  cocain  is  at  times  a  dis- 
advantage, whereas,  under  the  use  of  eucain,  this  disadvantage  does 
not  occur.  Instilled  into  the  eye  its  solution  causes  mild  hyperemia, 
but  does  not  produce  dilatation  of  the  pupil  or  loss  of  accommodation, 
and  its  use  is  not  followed  by  the  changes  in  the  corneal  epithelium 
sometimes  produced  by  cocain;  notwithstanding  these  advantages, 
the  anesthesia  which  it  produces  has  not  been  thoroughly  satisfactory, 
and  it  has  never  become  very  popular  with  ophthalmologists.  This 
agent,  in  its  time  the  most  satisfactory  substitute  for  cocain  for  use 
in  general  surgery,  and  marking  a  decided  advance  in  the  progress  of 
local  anesthetics,  has  now  been  largely  superseded  by  novocain, 
which  possesses  all  the  advantages  claimed  for  eucain  with  others  in 
addition. 

During  the  European  War  when  novocain  was  no  longer  obtain- 
able, eucain  became  the  agent  of  choice  and  has  been  in  daily  use  in  a 
large  number  of  cases  in  our  clinic  with  the  most  satisfactory  results. 
For  very  sensitive  regions  and  those  well  supplied  with  nerves  as  in 
herniotomy,  hemorrhoidectomy  and  prostatectomy  I  prefer  a  0.4  per 
cent,  solution  with  0.4  per  cent,  sodium  chloride  but  for  ordinary 
infiltration  the  Braun  solution  0.2  percent,  will  prove  amply  sufficient. 
I  have  much  to  say  in  recommendation  of  this  agent  and  place  it  Ion 
a  parity  very  little  below  that  of  novocain.  The  slight  delay  neces- 
sary (ten  to  fifteen  minutes)  to  obtain  its  full  anesthetic  action  and 
that  of  the  adrenalin  is  its  only  disadvantage,  but  if  as  much  of  the 
injecting  of  the  field  be  performed  as  possible  before  any  incisions  are 
made,  and  as  successive  planes  of  the  tissues  are  divided  and  the 
infiltration  kept  well  in  advance  of  the  operation  this  loss  of  time  is 
avoided  and  the  objection  to  its  use  is  not  apparent.  From  my  own 
close  observation  of  its  action  I  have  the  following  to  say :  When  first 
injected  into  the  tissues  it  produces  a  decided  hyperemia  and  is  less 
readily  affected  by  adrenalin.  These  qualities  may  prompt  the 
operator  to  form  an  unsatisfactory  opinion  of  this  agent  on  his  first 
experience  with  it,  this  opinion  will  however  change  on  a  more  thor- 
ough acquaintance  with  its  action.  The  principal  points  to  be  ob- 
served are  the  following: 

i.  It  is  slower  in  action  than  cocain  or  novocain,  but  apparently 
fully  equal  to  either  in  equal  strength  after  a  short  interval  for  sat- 
uration, usually  ten  to  fifteen  minutes. 


LOCAL   ANESTHETICS  8 1 

2.  It  is  far  less  toxic  than  cocain  and  very  closely  approaches  in 
this  respect  the  weak  toxicity  of  novocain. 

3.  With  adrenalin:  when  first  injected  no  effect  from  the  adrenalin 
is  observed  but  a  decided  vaso-dilatation  from   the  eucain,    this 
gradually  disappears  and  is  replaced  by  a  decided  ischemia,  fully  as 
marked  as  that  resulting  from  the  use  of  cocain  or  novocain  with 
adrenalin  in  equal  strength. 

4.  The  duration  of  anesthesia  compares  very  favorably  with  the 
above  agents  and  usually  exceeds  one  hour. 

5.  No  irritant  action  has  been  observed  following  its  use  and 
wounds  heal  as  kindly  as  with  any  other  method. 

AKOIN 

Closely  related  to  holocain  is  a  white  crystalline  powder  of  bitter 
taste.  The  hydrochlorate  is  soluble  in  water  to  6  per  cent.,  and  freely 
so  in  alcohol.  It  possesses  decided  antiseptic  qualities.  It  is  decom- 
posed by  alkalis.  Compared  with  cocain,  it  is  slightly  slower  and 
weaker  in  action  and  slightly  more  toxic,  and  its  poisonous  action  is 
of  longer  duration.  It,  however,  possesses  the  particular  quality  of 
producing  prolonged  anesthesia,  sometimes  lasting  several  hours.  Its 
injection  is  quite  irritating,  strong  solutions  decidedly  so;  5  per  cent, 
solutions  are  said  to  have  caused  necrosis.  As  ordinarily  recom- 
mended, in  0.20  to  0.5  per  cent,  solutions,  its  injurious  action  is  not 
so  manifest,  but  even  these  weak  solutions  frequently  leave  behind  a 
slight  painful  induration.  Possessing  as  it  does  the  power  of  produc- 
ing a  prolonged  anesthesia,  it  at  one  time  enjoyed  considerable  popu- 
larity, but  since  the  introduction  of  adrenalin  this  advantage  is  not  so 
apparent.  It  was  particularly  combined  in  weak  solutions  with 
other  anesthetics,  thus  utilizing  some  of  its  desirable  qualities  while 
preventing  its  primary  irritation,  and  greatly  prolonging  the  post- 
operative anesthesia.  These  qualities  are  particularly  desirable  in 
all  operations  about  the  anus,  hemorrhoids,  etc. 

HOLOCAIN 

Holocain  hydrochlorid,  a  synthetic  preparation  introduced  into 
medicine  in  1897,  is  derived  from  the  same  source  as  phenacetin, 
with  which  it  is  often  adulterated.  It  is  decomposed  by  alkalis,  but 
stands  a  moderate  degree  of  boiling.  It  is  moderately  soluble  in 
water,  and  more  toxic  than  cocain.  Its  action  is  quite  irritant,  fol- 
lowed later  by  anesthesia.  Owing  to  its  irritant  action  it  is  rarely 


82  LOCAL   ANESTHESIA 

used  for  infiltration,  but  finds  its  principal  field  of  usefulness  in  ocular 
surgery.  When  instilled  into  the  eye  in  i  per  cent,  solution,  the 
strength  usually  advised,  it  produces  a  moderate  degree  of  burning, 
followed  in  about  fifteen  seconds  to  one  minute  by  anesthesia,  which 
lasts  about  ten  to  twenty  minutes.  Its  particular  claims  for  useful- 
ness here  are  its  decided  antiseptic  qualities;  it  does  not  affect  the 
circulation  or  produce  corneal  drying  as  does  cocain,  does  not  produce 
mydriasis,  affect  accommodation  or  intra-ocular  pressure;  these 
qualities  make  it  valuable  in  treating  corneal  ulcerations  and  in  re- 
moving foreign  bodies  from  the  eye ;  it  does  not  control  hemorrhage,  as 
does  cocain  and  this  is  considered  in  its  favor,  as  the  escaping  blood 
often  washes  away  bacteria  which  might  otherwise  gain  an  entrance 
into  the  tissues.  Notwithstanding  its  irritant  qualities,  its  other 
desirable  features,  when  used  in  the  eye  in  combination  with  its  dual 
properties,  of  anesthesia  and  antisepsis,  demand  for  it  a  certain  place 
in  ophthalmologic  surgery. 

An  investigation  undertaken  at  the  Johns  Hopkins  Hospital  to 
determine  its  value  as  an  antiseptic  arrived  at  the  following  conclu- 
sions: It  exerts  a  distinct  antiseptic  influence  upon  ordinary  pus- 
organisms  and  the  Micrococcus  epidermidis  albus.  No  attempt  was 
made  to  determine  the  exact  point  of  time  in  which  these  organisms 
lose  their  vitality  when  exposed  to  i  per  cent,  solutions,  but  it  is 
somewhere  around  twenty-four  hours,  but  these  organisms  were 
found  to  grow  on  agar  containing  0.5  per  cent,  holocain. 

TROPACOCAIN 

This  agent,  benzoyl-tropein,  was  first  isolated  from  the  coca  plant 
of  Java  by  Giesel,  and  studied  physiologically  by  Chadbourne,  who 
ascribes  to  it  an  action  identical  with  cocain,  except  that  it  is  of  much 
quicker  action  and  of  shorter  duration  than  cocain  and  is  about  one- 
half  as  toxic;  it  produces  no  change  in  the  vascularity  of  the  tissues 
with  which  it  is  brought  in  contact.  Toxic  symptoms  arising  from 
its  use  are  usually  of  much  shorter  duration  than  those  produced  by 
cocain.  When  instilled  into  the  eye  in  watery  solution  it  produces 
anesthesia  of  the  cornea  in  about '  one-half  the  time  necessary  for 
similar  solutions  of  cocain,  but  producing  no  ischemia  or  paralysis  of 
accommodation  and  but  slight  mydriasis;  the  anesthesia  is  slightly 
less  intense  than  that  produced  by  similar  strength  solutions  of 
cocain. 

It  has  little  to  commend  it  for  general  use,  and  has  consequently 
not  become  very  popular,  but  seems  to  be  more  suited  to  spinal 


LOCAL    ANESTHETICS  83 

analgesia  than  any  other  agent  so  far  introduced,  as  fewer  fatalities 
have  followed  its  use  in  this  field. 

STOVAIN 

A  derivative  of  the  benzoyl  group,  first  produced  by  Tourneau 
after  whom  it  was  named.  Tourneau  in  French  means  stove,  hence, 
the  Anglocised,  S  to  vain.  Introduced  as  a  substitute  for  cocain,  is  a 
white  powder  easily  soluble  in  water;  its  solutions  stand  a  limited 
amount  of  boiling,  but  are  decomposed  when  heated  to  i2o°C.;  it  is 
said  to  be  unsuited  to  combination  with  adrenalin. 

The  French  school  by  which  this  drug  was  introduced  have  been 
particularly  active  in  pushing  it  forward,  notably  Tuffier  and  Reclus. 
It  was  especially  recommended  for  spinal  puncture,  in  which  it  was 
at  one  time  extensively  used.  After  a  more  extended  use  its  irritating 
qualities,  especially  to  nerve-tissues,  becoming  more  apparent,  it  has 
been  less  used  than  formerly.  For  especial  consideration  of  the 
changes  induced  in  nerve-tissue,  consult  chapter  on  Spinal  Analgesia. 

A  claim  advanced  for  it  in  spinal  analgesia  is  that  it  induces  a 
greater  relaxation  of  all  the  sphincteric  outlets  than  is  accomplished 
by  the  use  of  any  other  agent.  It  is  generally  conceded  as  being 
slightly  less  toxic  and  less  powerful  than  cocain  and  its  anesthesia  of 
slightly  less  duration;  its  toxic  symptoms  when  manifest  are  very 
similar  to  those  induced  by  cocain.  Its  dilute  solution,  injected  into 
the  tissues,  causes  a  slight  burning  pain,  which  is  soon  followed  by 
anesthesia,  and  frequently  leaves  a  postanesthetic  inflammatory 
reaction;  strong  solutions  up  to  10  per  cent,  are  very  likely  to  be 
followed  by  tissue  necrosis.  Sinclair  reports  this  occurrence  follow- 
ing the  use  of  a  2  per  cent,  solution.  It  has  been  tried  in  the  eye,  but 
has  not  met  with  much  favor  here  owing  to  its  irritating  qualities. 
This  agent  will  be  discussed  more  at  length  in  the  latter  part  of  this 
chapter,  in  the  comparative  study  of  the  action  of  the  different 
anesthetics. 

ALYPIN 

Introduced  in  1905  by  Impens,  is  of  rather  complex  chemical 
formula,  a  derivative  of  the  benzoyl  group,  and  closely  related  to 
stovain;  is  a  white  crystalline  powder  of  neutral  reaction,  easily  solu- 
ble in  water  and  alcohol,  sparingly  so  in  ether,  not  decomposed  by 
moderate  boiling  nor  precipitated  by  moderate  quantities  of  sodium 
bicarbonate.  This  agent  was  introduced  as  a  substitute  for  cocain  to 
overcome  some  of  the  unpleasant  effects  of  the  latter;  in  this  it  has 


84  LOCAL   ANESTHESIA 

been  only  partially  successful.  The  results  obtained  by  the  investi- 
gations of  the  German  school  of  investigators  on  the  one  hand,  and 
the  French  and  English  on  the  other,  do  not  entirely  agree  in  all 
particulars  regarding  the  toxicity  and  action  of  this  agent.  The 
Germans  claim  it  to  be  non-irritant  and  less  toxic  than  cocain,  while 
the  French  and  English  claim  it  to  be  irritant  and  slightly  more  toxic 
than  cocain.  Our  personal  observations  in  the  use  of  this  agent 
rather  incline  us  to  a  position  intermediate  between  to  the  two.  For 
the  result  of  the  comparative  study  of  this  and  other  agents,  consult 
the  latter  part  of  this  chapter.  Regarding  its  anesthetic  power  it  is 
about  equal  to  cocain,  and  is  especially  recommended  for  ophthalmic, 
nose,  and  throat  surgery,  although  it  finds  certain  indications  for  use 
in  general  surgery.  Schleich  combines  it  with  cocain  in  his  three 
anesthetic  solutions,  reducing  the  cocain  in  each  one-half  and  adding 
an  equal  quantity  of  alypin;  by  this  combination  lessening  the  tox- 
icity of  each  as  well  as  enhancing  the  total  anesthetic  effect,  according 
to  Burgi's  contention,  explained  elsewhere  in  this  volume.  While 
the  combination  of  different  anesthetic  salts  in  solution  is  thoroughly 
rational  and  has  certain  advantages,  if  such  combinations  were  to  be 
made  we  would  prefer  the  use  of  novocain  to  alypin.  The  injection 
of  solutions  of  alypin  as  ordinarily  used  at  times  causes  a  slight  burn- 
ing, and  is  followed  by  some  hyperemia,  and  in  some  cases  slight 
inflammation  has  followed  its  use;  this,  however,  is  less  marked  than 
with  stovain.  Compared  with  cocain  it  exercises  about  an  equal 
anesthetic  power,  but  of  slightly  less  duration;  this  is  probably  due  to 
the  ischemia  induced  by  cocain  retarding  absorption,  while  the  hypere- 
mia induced  by  alypin  favors  it;  this  can,  however,  be  overcome 
by  the  addition  of  adrenalin,  with  which  alypin  is  thoroughly 
compatible. 

Instilled  into  the  eye,  its  4  per  cent,  solution  causes  a  slight  burn- 
ing followed  by  anesthesia  in  about  twenty-five  seconds,  and  in  one 
minute  this  anesthesia  is  sufficiently  profound  to  permit  the  curetting 
of  corneal  ulcers,  their  cauterization,  the  removal  of  foreign  bodies, 
and  other  superficial  operations.  Its  advantages  within  the  eye  are 
that  it  does  not  cause  drying  of  the  corneal  epithelium,  dilatation  of 
the  pupil,  or  changes  in  accommodation  or  tension. 

In  the  nose  and  throat,  but  more  particularly  in  the  nose,  are 
its  advantages  sometimes  apparent,  particularly  in  the  removal  of 
posterior  hypertrophies  of  the  turbinates,  where  the  shrinkage  in- 
duced by  cocain  is  sometimes  a  decided  disadvantage;  the  same  ad- 
vantages are  noticed  with  polypi;  further  advantages  claimed  for  it  are 


LOCAL   ANESTHETICS  85 

that  its  taste  is  not  so  bitter  as  cocain,  and  it  does  not  cause  the  same 
sensation  of  choking  or  lump  in  the  throat,  which  is  sometimes  annoy- 
ing to  nervous  patients.  Some  operators  claim  an  advantage  for  it 
when  used  without  adrenalin  for  the  removal  of  tonsils,  as  it  does  not 
cause  a  vasoconstriction;  any  hemorrhage  that  will  occur  takes  place 
at  the  time  of  operation  and  not  postoperative. 

Prof.  Bransford  Lewis  has  especially  recommended  it  for  use  in 
the  posterior  urethra  and  bladder  as  a  means  of  anesthesia  prepara- 
tory to  cystoscopy,  using  for  this  purpose  specially  prepared  tablets 
containing  i^  gr.  of  the  drug;  these  are  deposited  in  the  posterior 
urethra  with  a  special  depositor,  and,  after  allowing  time  for  the 
tablet  to  be  softened  by  the  mucus,  the  mass  is  then  smeared  over  the 
adjacent  membrane  by  a  to-and-fro  movement  of  the  depositor.  He 
claims  that  this  agent  gives  thorough  satisfaction  when  used  in  this 
way,  requiring  about  five  to  ten  minutes  to  produce  sufficient  anes- 
thesia for  the  introduction  of  the  cystoscope. 

Dr.  Willy  Meyer  also  recommends  it  in  the  genito-urinary  tract, 
but  uses  instead  of  the  tablet  instillation  of  a  2  per  cent,  solution. 
If  the  claims  of  a  lesser  toxicity  of  this  agent  as  compared  with  cocain 
had  been  thoroughly  established,  it  might  find  a  more  extended  use, 
but  from  our  experience  we  must  regard  it  as  fully  as  toxic;  it,  never- 
theless, finds  a  certain  field  of  usefulness  for  special  work,  particularly 
in  the  eye,  nose,  and  throat.  Where  silver  nitrate  is  to  be  applied  to 
mucous  surfaces  and  external  parts,  alypin  nitrate  has  been  intro- 
duced by  the  manufacturers  as  a  substitute  for  the  plain  salt,  which 
to  some  extent  neutralizes  the  effect  of  silver  nitrate  through  chemical 
decomposition.  This  is  not  the  case  with  alypin  nitrate,  and  its 
anesthetic  effects  are  not  destroyed  by  the  application  of  silver 
nitrate;  its  chemical  characteristics,  solubility,  and  strength  of  solu- 
tions essentially  correspond  to  those  of  alypin. 

NOVOCAIN  HYDROCHLORID 

With  the  introduction  of  this  agent  the  ceaseless  efforts  and 
zealous  endeavors  of  the  numerous  workers  in  the  field  of  synthetic 
anesthetics  has  at  last  been  crowned  with  a  very  decided  degree  of 
success  in  obtaining  an  effective  agent  absolutely  non-irritant  and  of 
low  toxicity,  which  qualities  are  of  vital  consideration  for  the  general 
use  of  a  loeal  anesthetic.  Some  of  the  many  substitutes  for  cocain 
already  introduced  have  exhibited  advantages  in  one  or  the  other 
direction,  but  none  of  them  have  fulfilled  all  of  the  prime  considera- 
tions, particularly  those  of  lack  of  toxicity  and  irritating  qualities, 


86  LOCAL   ANESTHESIA 

which  in  some  of  these  agents  has  been  so  marked  that  their  strong 
solutions  produce  almost  a  corrosive  action.  The  absence  of  irritat- 
ing qualities  in  novocain  is  most  marked,  even  when  applied  in 
powder  form  or  concentrated  solution  to  sensitive  wounds  in  the  most 
delicate  tissue  and  on  such  surfaces  as  the  cornea.  Novocain,  which 
is  the  hydrochlorid  of  para-aminobenzoyldiethylaminolthanol,  is  a 
white  crystalline  powder  of  neutral  reaction  and  possesses  the 
formula : 

NH2 


HC     CH 
HC     CH 


5)2;  HC1,  was  introduced  by  Einhorn  in  1905. 
It  is  soluble  in  water  i  to  i  and  in  alcohol  in  i  to  30;  it  melts  at  i56°C. 
and  can  be  heated  in  i2o°C.  without  decomposition.  Its  solutions 
possess  slight  antiseptic  properties,  and  are  capable  of  repeated  boil- 
ings without  apparently  affecting  their  strength,  and  may  be  kept  for 
long  periods  of  time  (several  months) ,  a  quality  not  possessed  by  any 
of  the  other  anesthetic  agents. 

Like  other  agents  of  this  group  its  solutions  are  precipitated  by 
alkalis  and  alkaline  carbonates,  with  the  exception  in  favor  of  novo- 
cain that  it  is  not  precipitated  or  its  solutions  rendered  turbid  by 
sodium  bicarbonate. 

The  physiologic  investigation  of  novocain  shows  that  it  produces 
no  mydriasis,  no  disturbances  of  accommodations,  and  no  increase  hi 
intra-ocular  pressure.  The  effect  of  moderately  large  doses  upon  the 
general  system,  when  absorbed  by  either  the  intravenous  or  subcuta- 
neous route,  show  almost  no  perceptible  change  either  upon  the 
circulation  or  respiration,  and  practically  no  changes  were  observed 
in  the  blood-pressure  or  respiration  when  studied  by  the  kymograph. 
Numerous  investigations  by  competent  observers  regarding  its 
relative  toxicity  (see  latter  part  of  this  chapter)  all  agree  in  giving  it 
a  toxicity  from  one-fifth  to  one-seventh  of  that  of-cocain,  while 
studies  made  to  determine  its  relative  activity  seem  to  show  1.25  per 
cent,  solutions  equal  in  anesthetic  activity  to  i  per  cent,  solutions  of 
cocain,  though  possessing  a  slightly  shorter  duration  of  action.  On 
the  other  hand,  this  agent  when  combined  with  adrenalin  solutions 


LOCAL    ANESTHETICS  87 

possesses  the  highly  desirable  quality  of  having  its  action  greatly 
intensified,  more  so  than  that  of  any  other  similarly  used  agent. 
Solutions  of  equal  strength  equal  in  activity  those  of  cocain,  though 
slightly  slower  in  action,  but  often  yielding  an  anesthesia  of  longer 
duration  than  equal  strengths  of  cocain  similarly  used. 

Injected  within  the  tissues,  even  in  strong  solution,  novocain 
exerts  but  little  or  no  influence  upon  the  vasomotors  of  the  part;  its 
injections  are  without  pain  and  seem  to  be  absolutely  free  from  all 
irritation;  no  after-pain,  inflammation,  hyperemia,  or  induration  has 
been  observed  to  follow  its  action.  It  is  further  claimed  for  novocain 
that  where  it  is  necessary  to  make  repeated  use  of  this  agent  that  no 
danger  of  the  formation  of  a  habit  need  be  anticipated. 

The  remarkably  favorable  action  obtained  by  the  combination  of 
adrenalin  preparations  with  novocain,  as  well  as  its  total  absence  of 
all  irritation,  is  well  shown  in  the  following  experiments  of  Prof. 
Braun,  published  in  the  "Deutsch.  Med.  Wochenschrift,"  1905,  No. 
42: 

"  i.  Isotonic  solution  of  novocain  (o.i  per  cent.).  Formation  of  a  cutaneous  wheal 
on  the  forearm.  Injection  painless.  The  anesthetic  action,  like  that  of  tropacocain, 
was  of  very  short  duration,  and  in  from  three  to  five  minutes  cutaneous  sensibility 
returned.  No  hyperemia.  The  wheal  vanished  without  leaving  a  trace. 

"2.  Solutions  of  novocain  (0.5  and  i  per  cent.).  Formation  of  cutaneous  wheals. 
Injection  painless.  Duration  of  wheal  anesthesia  fifteen  minutes.  Wheals  vanished 
leaving  no  trace.  No  hyperemia. 

"3.  Solutions  of  novocain  (5  and  10  per  cent.).  Formation  of  wheals.  Injection  of 
5  per  cent,  solution  painless;  10  per  cent,  solution  produced  very  slight  irritation.  Dura- 
tion of  anesthesia  seventeen  and  twenty-seven  minutes,  respectively.  Very  slight 
hyperemia  at  site  of  injection.  Wheals  vanished.  No  infiltration  or  tenderness 
remained. 

"4.  Novocain  solution  (i  per  cent.),  i  c.c.  injected  subcutaneously  into  forearm 
in  region  of  superficial  radial  nerve.  Soon  after  the  skin  over  the  injected  area  showed 
diminished  sensibility.  No  distinct  evidence  that  the  peripheral  nerve-twigs  were 
anesthetized. 

"5.  Novocain  solution  (0.5  per  cent.).  Constriction  of  little  finger  with  rubber 
tube.  Injection  of  i  c.c.  of  solution  circularly  into  the  subcutaneous  tissue  of  the  first 
phalanx.  After  eleven  minutes  entire  finger  completely  insensible.  Rubber  tubing 
removed.  In  five  minutes  sensibility  had  returned.  No  swelling  or  sensitiveness 
remained  in  finger. 

"  We  have  to  do,  therefore,  with  a  local  anesthetic  with  a  strong,  yet  in  comparison 
with  some  others,  a  transitory  action,  like  that  of  tropacocain.  In  order  to  obtain  results 
comparable  with  those  from  cocain,  it  would  be  necessary  to  use  concentrated  solutions 
and  large  doses  in  proportion  to  the  slight  toxicity  of  novocain.  However,  this  neces- 
sity is  readily  and  successfully  overcome  by  the  addition  of  suprarenin  to  the  novocain 
solutions. 

"6.  Isotonic  novocain  solution  (o.i  per  cent.).  To  100  c.c.  add  5  drops  1:1000 
suprarenin  solution.  Formation  of  cutaneous  wheals  on  the  forearm.  Injection  pain- 
less. Very  marked  anemia.  Duration  of  anesthesia  more  than  an  hour.  No  reaction 
of  any  kind. 


88  LOCAL   ANESTHESIA 

"7.  Novocain  solution  (i  per  cent.),  each  cubic  centimeter  of  which  contained  2 
drops  of  suprarenin  solution  i :  1000.  Formation  of  wheals  on  forearm.  Anesthesia 
extended  far  beyond  limits  of  wheals.  Duration  nearly  four  hours.  Marked  suprarenin 
anemia,  upon  subsidence  of  which  some  after-pain.  No  other  reaction. 

"8.  i  c.c.  of  the  same  solution  injected  beneath  skin  of  forearm.  The  skin  over  the 
site  of  injection,  as  well  as  in  the  course  of  the  sensitive  nerves,  was  anesthetic  for  two 
hours.  Marked  suprarenin  action.  No  reaction. 

"9.  Novocain  solution  (0.5  per  cent.)  with  addition  of  i  drop  of  suprarenin  solution 
(i :  1000)  to  each  cubic  centimeter;  i  c.c.  injected  beneath  the  skin  of  the  first  phalanx  of 
the  fourth  finger.  In  ten  minutes  finger  anesthetic  and  anemic.  Sensibility  began  to 
return  in  sixty-five  minutes.  Another  hour  elapsed  before  complete  return  of  sensibil- 
ity. No  after-pain." 

The  conclusion  of  Braun's  observations  are  that  novocain  actually 
increases  the  action  of  adrenalin,  while  Biberfeld,  after  studying  the 
same  subject,  states  that  novocain  is  the  only  local  anesthetic  which 
does  not  arrest  or  weaken  the  action  of  adrenalin.  Our  own  obser- 
vations on  this  subject,  drawn  from  a  large  number  of  clinical  cases, 
is  not  thoroughly  in  accord  with  those  of  the  above  investigations  on 
some  few  points- — viz.,  we  have  never  observed  the  same  degree  of 
ischemia  of  the  tissues  when  working  with  our  solution  No.  i  (0.25 
per  cent,  novocain)  plus  15  to  20  drops  of  adrenalin  (i :  1000)  to  each 
3  or  4  ounces  of  solution,  as  when  using  equal  quantities  of  adrenalin 
with  similar  solutions  of  cocain,  although  the  intensity  of  anesthesia 
was  fully  equal  to  that  produced  by  the  cocain  solutions  and  the 
duration  of  its  anesthesia  often  longer. 

Novocain  has  not  become  universally  popular  for  purely  topical 
applications  in  the  nose  and  throat,  although  it  always  succeeds 
satisfactorily  when  used  for  infitration,  especially  in  combination  with 
adrenalin.  It  is  probable  that  the  failure  of  some  operators  to  secure 
satisfactory  results  from  its  local  application  in  the  concentrated 
solutions  (10  per  cent.)  usually  used  for  this  work  is  due  to  the  fact 
that  insufficient  time  has  been  allowed  for  its  absorption,  as  it  is 
somewhat  slower  in  action  than  cocain;  but,  in  view  of  its  much  re- 
duced toxicity,  its  action  here  should  be  encouraged,  as  it  is  in  this 
particular  field  that  so  many  toxic  cases  occur. 

Its  action  in  the  geni to-urinary  tract,  urethra  and  bladder,  has 
proved  fully  as  satisfactory  as  that  of  any  other  similarly  used  agent 
when  a  slightly  longer  time  has  been  allowed  for  its  action. 

Novocain  nitrate  has  been  introduced  for  especial  use  within  the 
urethral  tract  and  elsewhere  when  silver  nitrate  and  other  silver  salts 
are  to  be  used,  as  it  is  compatible  with  combinations  of  silver.  It  is 
particularly  recommended  for  employment  with  the  various  silver 
salts  for  urethral  injections,  using  the  novocain  nitrate  in  i  to  3  per 


LOCAL   ANESTHETICS  89 

cent,  solutions  in  combination  with  such  agents  as  albargin,  protar- 
gol,  etc. 

For  reference  to  its  other  methods  of  use  here,  see  chapter  on 
General  Technic,  as  well  as  the  chapters  on  the  special  subjects. 

Thus  far  the  observations  made  with  novocain  in  ophthalmologic 
practice  rather  point  to  the  conclusion  that  cocain  will  still  remain  the 
anesthetic  of  choice  in  this  particular  field,  due  largely  to  the  slowness 
of  action  of  novocain  and  its  inability  to  penetrate  and  anesthetize 
the  tissues  deeply  following  topical  applications.  However,  certain 
advantages  possessed  by  it  over  cocain  are  the  absence  of  drying  and 
injury  to  the  superficial  corneal  epithelium  so  often  noted  following 
the  use  of  cocain.  This  was  studied  by  Gebb  on  the  cornea  of  rabbits 
holding  the  eye  open  by  self-retaining  speculi  and  treating  the  eye 
with  10  per  cent,  solutions  of  novocain;  after  twenty  minutes  abso- 
lutely no  change  could  be  noted  in  the  epithelia,  which  was  in  marked 
contrast  to  the  effects  noticed  following  the  similar  use  of  cocain. 
When  dropped  into  the  eye  in  powder  form  slight  transitory  changes 
were  noted  which  had  entirely  disappeared  after  two  hours,  while 
cocain  similarly  employed  may  be  followed  by  more  lasting  or  serious 
changes,  sometimes  terminating  in  leukoma. 

Notwithstanding  the  advantages  possessed  by  it,  due  to  its  com- 
parative lack  of  irritation,  cocain  when  cautiously  and  carefully  used 
still  remains  the  agent  of  choice  in  this  field. 

After  a  rather  extended  experience,  including  a  large  number  of 
cases  embracing  the  entire  field  of  surgery  in  which  this  agent  has  been 
almost  exclusively  used,  we  have  failed  to  note  a  single  case  in  which 
there  has  been  any  unpleasant  local  or  constitutional  action.  We, 
therefore,  feel  thoroughly  justified  in  unqualifiedly  recommending  it 
as  the  safest,  most  reliable,  and  satisfactory  of  any  local  anesthetic 
agent  yet  introduced. 

Novocain  base  (soluble  in  oils)  has  also  been  put  upon  the  market, 
and  is  intended  for  special  uses  where  oily  preparations  are  to  be 
employed. 

CHLORETONE 

Chloretone  was  discovered  in  1881  by  Willgerodt,  and  suggested 
as  a  substitute  by  him  for  chloral  in  1884.  It  was,  however,  not 
until  1897  that  its  active  manufacture  was  undertaken  by  Hoffman, 
La  Roche  &  Co. 

It  is  formed  by  the  action  of  potassium  hydroxid  upon  acetone 
and  chloroform;  the  result  of  this  action  is  a  white  camphoraceous 


90  LOCAL   ANESTHESIA 

powder,  first  called  aneson  or  anesin  and  later  renamed  chloretone. 
It  is  soluble  in  warm  water  to  i  per  cent.,  0.8  per  cent,  in  cold  water, 
quite  soluble  in  oils  and  glycerin,  and  very  soluble  in  alcohol,  ether, 
benzin,  glacial  acetic  acid,  chloroform,  and  acetone.  It  is  a  very 
stable  chemical  compound  and  is  unaffected  by  heat  or  light.  It  is 
quite  compatible  in  mixtures  of  bichlorid  of  mercury,  carbolic  acid, 
thymol,  etc. 

It  is  particularly  an  antiseptic,  local  anesthetic,  and  hypnotic. 
It  was  expected  that  a  drug  possessing  such  valuable  chemical  and 
therapeutic  properties  would  prove  highly  useful,  but  in  this  respect 
it  has  not  fulfilled  the  expectations  of  the  profession. 

Internally  administered,  it  readily  passes  into  the  circulation  and 
is  decomposed  within  the  body,  as  none  of  it  can  be  recovered  from 
the  urine  or  expired  air.  In  large  doses  chloretone  causes  in  lower 
animals  a  profound  sleep,  associated  with  complete  and  prolonged 
anesthesia;  this  occurs  without  marked  effect  on  respiration  heart, 
action,  or  blood-pressure.  This  sleep  may  sometimes  last,  several 
days  and  the  animal  awake  unharmed,  but  if  too  large  a  dose  is  ad- 
ministered death  will  occur  from  asphyxia  after  two  or  three  days' 
sleep. 

One  inconvenience  regarding  its  administration  is  its  insolubility 
in  ordinary  menstruums;  it  is,  however,  fairly  safe  and  20  to  40  gr.  can 
be  administered  to  an  adult  at  one  time. 

When  locally  applied  to  denuded  areas  it  first  exerts  an  irritant 
action,  followed  in  a  short  time  by  a  very  decided  degree  of  anesthesia 
injected  hypodermically  into  the  tissues  it  is  quite  irritating,  but  is 
followed  by  marked  anesthesia,  the  site  of  the  injection  remaining  for 
some  time  as  a  painful  induration.  According  to  Kossa  and  Vam- 
ossy,  it  possesses  greater  anesthetic  powers  than  cocain,  but  is  slower 
in  action  and  less  penetrating.  They  state  that  a  i  per  cent,  solu- 
tion equals  in  activity  a  2.8  per  cent,  solution  of  cocain.  This  remark- 
able statement  has,  however,  not  been  confirmed  by  others.  How- 
ever, its  undesirable  irritating  action  condemn  it  as  a  useful  local 
anesthetic ;  combining  marked  anesthesia  with  antisepsis  and  hypno- 
sis it  will  always  enjoy  a  fair  range  of  usefulness. 

Its  anesthetic  action  is  manifested  along  the  gastro-intestinal 
tract,  where  it  proves  a  valuable  gastric  sedative.  Possessing  as  it 
does  decided  antiseptic  properties,  it  is  quite  useful  in  such  conditions 
as  gastric  ulcer  and  gastric  irritation,  with  emesis  from  other  causes, 
such  as  seasickness.  It  is  useful  as  a  preventive  to  nausea  incident 
to  general  anesthesia ;  when  used  for  this  purpose  it  should  be  given  in 


LOCAL   ANESTHETICS  9 1 

io-  to  i5-gr.  doses  about  one  hour  before  anesthesia.  It  has  been 
stated  by  Hirschman  that  in  cases  so  treated  very  few  are  nauseated 
after  the  anesthetic,  and  that  few,  if  any,  vomit  during  the  anesthesia; 
its  further  advantages  during  this  state  are  due  to  its  hypnotic  quali- 
ties, which  lessens  the  quantity  of  the  anesthetic  necessary  and  pro- 
longs the  anesthetic  sleep.  Locally  applied,  chloretone  would 
suggest  itself  as  applicable  to  a  multitude  of  surgical  conditions,  such 
as  ulcers,  burns,  wounds,  hemorrhoids,  rectal  fissures,  insect  bites, 
etc.,  particularly  so  owing  to  the  facility  with  which  it  lends  itself  to 
combination  in  solutions  with  other  antiseptics  as  well  as  in  powders; 
the  disappointing  feature,  however,  is  its  irritating  properties,  which 
at  times  are  quite  marked,  while  in  other  cases  this  is  not  so  apparent, 
its  anesthetic  action  quickly  setting  in.  We  have  used  it  repeatedly 
for  burns,  and  in  nearly  all  cases  with  very  happy  results;  as  it  is  very 
slightly  soluble,  it  remains  in  action  for  some  time.  It  is  best  used  in 
solution,  poured  over  the  dressings  as  often  as  the  occasion  demands, 
its  antiseptic  action  greatly  lessening  the  surface  infection;  if  the 
dressings  are  kept  constantly  wet  the  irritant  action  is  rarely  com- 
plained of,  as  the  anesthetic  action  is  maintained.  Its  absolute  in- 
nocuousness,  even  in  large  doses,  renders  it  a  safe  application  even 
for  large  surfaces;  any  effect  exercised  from  its  absorption  will  be 
hypnosis,  rather  a  desirable  action,  in  many  cases  lessening  or  entirely 
removing  the  need  for  narcotics.  Irritable  ulcers  and  chancroids 
similarly  treated  often  prove  very  satisfactory.  As  a  postoperative 
sedative  it  may  prove  useful  in  circumcision,  hemorrhoids  following 
the  use  of  the  cautery,  and  many  other  conditions,  either  in  solution, 
ointment,  or  dry  upon  the  wound;  incorporated  in  gauze,  it  proves 
useful  in  packing  irritable  wounds;  it  may  also  occasionally  prove 
useful  as  an  application  to  painful  cancerous  ulcerations. 

In  nose  and  throat  surgery  it  finds  a  field  of  usefulness  in  sprays 
for  ulcerated  and  inflamed  conditions  or  upon  packs  following 
operation. 

It  also  serves  a  use  in  dentistry,  exercising  its  antiseptic  and 
anesthetic  qualities  in  excavations,  alveolar  abscess,  etc. 

It  was  tried  in  combination  with  other  anesthetics  in  spinal  anal- 
gesia and  reported  on  by  Stone,  who  cites  200  favorable  cases,  but 
it  is  hardly  to  be  recommended  here  owing  to  its  irritant  action. 

Owing  to  this  unfortunate  quality  it  has  largely  been  super- 
seded by  other  agents,  notably  anesthesin,  but  its  greater  solubility 
and  antiseptic  properties  will  always  claim  for  it  a  certain  range  of 
usefulness. 


92  LOCAL   ANESTHESIA 

ORTHOFORM 

Orthoform,  nirvanin,  anesthesia,  and  subcutin  were  produced 
largely  as  the  results  of  the  efforts  of  the  synthetic  chemists  to  deter- 
mine if  the  complete  cocain  molecule  was  necessary  to  produce 
anesthesia,  as  well  as  to  see  if  by  certain  changes  in  this  molecule  the 
toxicity  could  be  reduced.  Orthoform  (old)  is  a  white  powder,  al- 
most insoluble,  and  possessing  decided  anesthetic  properties  when 
brought  into  contact  with  exposed  nerve-endings,  such  as  are  found 
on  raw  and  denuded  surfaces,  as  in  wounds,  ulcers,  gastric  vesical, 
and  rectal  lesions,  etc.  When  in  contact  with  such  surfaces  its  in- 
solubility renders  it  active  for  a  long  time  unless  washed  away.  This 
agent  possesses  decided  antiseptic  properties,  which,  combined  with 
its  anesthetic  power,  claimed  for  it  an  extensive  range  of  usefulness 
in  ointments  and  powders  to  burns,  ulcerated  surfaces,  chancroids, 
etc.,  for  this  reason  it  came  into  rather  extensive  use  until  its  toxic 
action  began  to  be  reported,  or  in  certain  cases  apparently  possessing 
idiosyncrasies. 

This  led  to  the  introduction  by  Einhorn,  in  1897,  of  orthoform 
(new),  which  is  meta-amido-para-oxybenzoic-acid-methylester.  In 
this  preparation  an  attempt  was  made  to  eliminate  the  objectionable 
toxic  qualities  of  orthoform  (old),  these  efforts  were,  however,  only 
partially  successful,  as  irritant  and  toxic  symptoms,  though,  as  a 
rule,  less  severe  and  less  frequent,  began  to  be  reported  from  the 
new  preparation.  One  advantage  which  this  agent  possesses  is  the 
ready  facility  with  which  it  lends  itself  to  combinations  with  many 
other  drugs,  being  thoroughly  compatible  with,  bichlorid  of  mer- 
cury, carbolic  acid,  iodin,  salicylic  acid,  calomel,  and  many  other 
preparations. 

It  also  found  a  rather  extended  field  of  usefulness  for  many  in- 
ternal as  well  as  external  conditions,  being  used  for  lesions  about  the 
nose,  throat,  and  larynx  with  the  same  facility  as  in  those  of  the  ex- 
posed parts. 

Toxic  symptoms  would  occasionally  develop  and  brought  this 
agent  into  disfavor. 

The  disturbances  likely  to  arise  from  the  use  of  orthoform  mani- 
fest themselves  as  a  dermatitis  with  more  or  less  severe  constitu- 
tutional  reaction,  and  occasionally  loss  of  tissue  at  the  point  of  ap- 
plication. These  symptoms  may  arise  from  a  few  days  to  several 
weeks  after  the  powder  has  been  in  use,  and  frequently  come  on 
abruptly  in  cases  where  the  powder  had  previously  given  perfect 


LOCAL   ANESTHETICS  93 

satisfaction;  its  action  in  this  respect  and  symptoms  are  very  sim- 
ilar to  those  occasionally  encountered  with  iodoform. 

The  symptoms  generally  begin  by  more  or  less  burning,  smart- 
ing, or  pain  in  the  wound  or  at  the  site  of  application,  a  pustular 
dermatitis  develops  about  the  wound  and  elsewhere  over  the  body 
associated  with  itching,  elevation  of  temperature;  rapid  pulse  and 
prostration  may  be  noted  in  the  severe  cases;  there  is  often  a  sticky 
discharge  af  a  peculiar  branny  or  doughy  odor  which  takes  place 
from  the  wound,  and  this  is  occasionally  accompanied  by  loss  of 
tissue  in  the  severe  cases. 

Since  the  advent  of  anesthesin,  which  possesses  none  of  the  ob- 
jectionable features  of  orthoform,  this  agent  has  now  been  almost 
entirely  supplanted. 

NIRVANIN 

Nirvanin,  of  rather  complex  chemical  formula,  is  a  soluble  form 
of  orthoform,  introduced  by  Einhorn  and  Heinze  in  1898,  is  a  white 
powder,  of  neutral  reaction,  easily  soluble  in  water,  and  possessing 
antiseptic  as  well  as  anesthetic  qualities,  and  is  not  decomposed  by 
heat.  Luxenburger,  who  investigated  this  substance,  found  it  to  be 
much  less  poisonous  than  cocain  and  fixed  the  maximum  dose  at  8 
gr.  Its  injection  causes  some  burning  pain,  while  no  injurious  action 
on  the  tissues  has  been  reported.  It  leaves  behind  a  slightly  tender 
hyperemic  area.  It  is  about  one-tenth  as  powerful  as  cocain,  and 
the  duration  of  its  action  is  much  shorter.  Its  feeble  action  prevents 
its  being  used  effectively  as  a  topical  application  to  mucous  mem- 
branes ;  its  irritant  action  makes  it  objectionable  in  the  eye.  At  first 
it  was  thought  that  it  would  become  very  popular  and  largely  super- 
sede cocain,  but  it  is  now  rarely  used. 

ANESTHESIN 

Two  notable  advances  were  recorded  in  the  pharmacology  of  local 
anesthetics  in  the  introduction  of  anesthesin  for  purely  topical  appli- 
cation and  novocain  for  infiltration.  These  agents  possess  so  many 
valuable  qualities  that  they  threaten  to  largely  supersede  the  use  of 
all  other  agents,  particularly  in  general  surgery.  Anesthesin  is  ethyl- 
para-amido-benzoate,  and  was  introduced  in  1890  by  Ritsert,  to 
whom  we  already  owed  much  in  the  synthesis  of  local  anesthetics. 
The  need  for  a  new  substance  was  felt  in  the  disappointing  qualities 
sometimes  exercised  by  orthoform,  which  anesthesin  was  intended 
to  replace.  That  this  want  has  been  well  filled  is  evidenced  by  the 


94  LOCAL   ANESTHESIA 

tremendous  satisfaction  expressed  on  all  sides  wherever  anesthesin 
has  been  used.  This  agent  is  a  fine,  white  crystalline  powder,  melting 
at  9O°C.,  almost  insoluble  in  cold  water,  but  slightly  so  in  hot  water, 
easily  soluble  in  alcohol,  ether,  benzin,  and  fatty  oils  (in  the  latter 
from  2  to  3  per  cent.).  It  is  not  decomposed  by  a  moderate  amount 
of  heat,  but  is  by  prolonged  boiling,  as  well  as  by  heating  it  with 
alkalis.  The  particular  qualities  of  this  drug  are  that  it  is  absolutely 
non-irritating,  almost  non-poisonous,  and  possesses  decided  anes- 
thetic qualities.  In  animal  experimentation  by  Binz,  in  which  large 
doses  were  given  to  rabbits,  it  was  found  to  exert  no  injurious  action, 
very  large  doses  producing  a  transient  methemoglobinemia,  but  no 
renal  irritation  or  methemoglobinuria.  These  facts,  with  numerous 
clinical  data,  in  which  large  doses  (30  to  40  gr.  daily)  have  been  given 
internally  without  noticeably  bad  effect,  would  tend  to  prove  that 
it  possesses  very  mild  toxic  properties. 

Regarding  its  physiologic  activity  anesthesin  very  closely  parallels 
orthoform,  but  is  superior  to  it  in  some  ways,  as  it  exerts  a  decided 
influence  on  intact  mucous  surfaces;  its  insolubility  requires  a  few 
minutes  for  it  to  exert  its  full  influence. 

Experiments  and  numerous  clinical  observations  have  proved 
that  anesthesin  is  tolerated  by  even  the  most  delicate  tissues  without 
the  slightest  irritation;  it  can,  therefore,  be  applied  quite  freely  to  all 
kinds  of  fresh  operative  wounds,  burns,  ulcers,  chancroids,  etc.,  with- 
out producing  the  least  irritation  or  other  unpleasant  after-effects. 

Internally  it  is  highly  useful  in  all  forms  of  gastralgia,  ulcer  of 
the  stomach  or  hyperesthesia,  vomiting  of  pregnancy,  etc.  In  the 
nose,  throat,  and  larynx  it  finds  a  very  decided  field  of  usefulness,  as 
insufflations,  inhalations,  painting  as  well  as  in  the  form  of  pastils,  in 
tuberculous,  syphilitic,  and  cancerous  ulcerations,  also  in  many  acute 
inflammatory  conditions.  In  a  series  of  experiments,  on  patients 
suffering  from  tubercular  laryngitis,  conducted  by  Prof,  von  Noorden, 
in  which  the  drug  was  used  in  10  per  cent,  emulsions,  3  per  cent,  solu- 
tions (water  with  45  per  cent,  alcohol)  and  by  insufflations,  all  three 
methods  gave  relief,  but  the  insufflations  proved  most  satisfactory. 

In  the  auditory  canal,  for  the  many  inflammatory  conditions  of 
these  parts,  after  a  preliminary  cleansing,  the  insufflation  of  the  pow- 
der or  its  use  in  strong  oily  emulsion  often  affords  very  gratifying 
relief. 

The  full  effect  of  anesthesin  is  noted  in  about  ten  minutes,  and  on 
external  surfaces,  where  it  remains  undisturbed,  this  action  persists 
from  several  hours  to  a  day. 


LOCAL   ANESTHETICS  95 

In  geni to-urinary  surgery  it  may  also  prove  quite  useful  when 
used  in  emulsion,  or  as  soluble  pencils  in  vesical  irritation,  due  to 
hyperesthesia,  ulcer,  tuberculoses,  or  malignancy  or  as  a  palliation 
in  stone,  and  in  similar  form  within  the  urethra  in  combination  with 
other  remedies. 

In  all  operations  about  the  rectum  it  is  highly  useful,  as  well  as 
in  the  palliative  treatment  of  such  conditions  as  ulcers,  fistula,  painful 
hemorrhoids,  or  anal  pruritus.  Following  operations  in  this  region 
the  free  use  of  the  preparation  as  a  powder,  or  20  per  cent,  ointment, 
will  relieve  almost  entirely  all  postoperative  pain.  Following  the  use 
of  the  cautery  on  chancroids  or  phagadenic  ulcers  it  will  allay  any 
after-burning.  For  irritable  and  painful  chancroids  we  have  found 
nothing  better.  A  marked  illustration  of  the  benefits  of  this  agent 
were  seen  in  a  case  of  chancroids  which,  during  self-treatment,  was 
severely  burned  with  pure  carbolic  acid  as  well  as  the  entire  head  of 
the  penis;  the  patient  was  in  great  distress,  nearly  frantic  from  the 
pain;  all  measures  which  had  been  tried  had  failed  to  give  relief. 
Strong  solutions  of  cocain  afforded  some  benefit,  but  were  too  tran- 
sient and  seemed  to  increase  the  inflammation,  besides  producing 
symptoms  of  absorption;  at  this  juncture  the  case  was  seen  by  one 
of  us,  and  pure  anesthesin  powdered  over  the  parts;  relief  was  com- 
plete in  about  five  minutes  and  lasted  for  about  six  hours,  when  the 
application  was  repeated.  Under  this  treatment  no  further  pain  was 
complained  of  and  the  wound  healed  in  about  the  usual  time. 

Applied  in  10  per  cent,  ointment  form  to  the  skin  it  has  proved 
highly  useful  in  allaying  the  pain  of  erysipelas  and  pruritus  from  toxic, 
diabetic,  nephritic,  and  other  causes,  also  in  the  intense  irritations 
sometimes  seen  in  cases  of  urticaria. 

Solutions  of  the  acid  salts  of  anesthesin  had  been  used  for 
hypodermic  use  for  infiltration  with  but  little  success,  as  during  the 
transformation  into  acid  salts  some  irritating  qualities  seem  to 
be  developed. 

In  conclusion,  we  may  say  that,  after  an  extended  use  of  this  agent 
in  a  great  variety  of  conditions,  we  have  never  yet  been  disappointed 
where  sedative  topical  applications  would  be  expected  to  give  relief. 

SUBCUTIN 

Subcutin  is  a  soluble  anesthesin  introduced  by  Ritsert,  and  formed 
by  the  action  of  paraphenolsulphuric  acid  upon  anesthesin;  it  is  said 
to  be  germicidal  and  non-toxic.  It  is  obtained  as  a  white  crystalline 
powder  of  acid  reaction,  soluble  in  water  up  to  i  per  cent.,  and  not 


g6  LOCAL   ANESTHESIA 

decomposed  by  boiling.  Its  injection  is  painless,  anesthesia  taking 
place  at  once,  but  it  is  stated  by  some  observers  to  be  followed  by 
considerable  inflammatory  after-effect.  It  is  a  much  less  powerful 
anesthetic  than  cocain  and  of  shorter  duration.  Its  irritant  action 
(like  anesthesin)  when  injected  makes  it  little  used  for  infiltration. 

PROPASIN 

A  white  crystalline  powder  of  neutral  reaction,  almost  tasteless 
and  odorless,  slightly  soluble  in  water,  easily  so  in  alcohol  and  ether, 
melting  at  74°C.  It  forms  salts  with  mineral  acids  and  is  decom- 
posed after  prolonged  boiling  with  alkalis. 

It  is  recommended  for  use  in  dermatology  and  in  the  gastroin- 
testinal tract.  Used  as  an  ointment,  10  to  15  per  cent.,  upon  the 
skin,  and  after  being  rubbed  in  it  produces  at  first  a  feeling  of  prick- 
ing, followed  shortly  by  anesthesia  of  prolonged  duration;  it  is  recom- 
mended as  a  dressing  for  ulcers,  pruritus,  etc. 

In  the  form  of  pastils  it  has  been  suggested  for  sore  throat  and 
internally  for  gastric  ulcers.  It  is  said  that  after  about  ten  minutes 
the  pain  leaves  and  a  numbness  sets  in  which  lasts  about  two  hours. 
The  internal  dose  is  2  or  3  gr.  which  can  be  repeated  several  times 
daily  without  any  apparent  harmful  effect. 

APOTHESINE 

It  is  with  much  pleasure  that  we  note  an  effort  on  the  part  of  our 
chemical  manufacturers  to  provide  us  with  drugs,  the  original  prod- 
ucts of  their  own  laboratories  and  make  us  independent  of  foreign 
sources  which  have  so  long  been  our  only  source  of  supply.  Apo- 
thesine,  recently  presented  in  experimental  quantities  by  an 
American  firm,  is  a  synthetic  product  of  their  laboratory.  Chemic- 
ally, it  is  the  cinnamic  ester  of  gamma-die thylamino  propyl  alcohol 
hydrochloride.  Apothesine  occurs  in  the  form  of  small  snow-white 
crystals,  having  a  melting  point  of  approximately  i37°C.  It  is 
easily  soluble  in  alcohol;  very  soluble  in  water;  and  slightly  soluble  in 
acetone  and  ether. 

During  a  clinical  experience  of  several  months,  I  have  been  very 
favorably  impressed  with  the  anesthetic  properties  of  this  product 
and  have  performed  hernia,  hemorrhoid,  fistula,  varicocele,  circum- 
cision and  plastic  operations.  I  have  uniformly  used  a  ^-per  cent,  solu- 
tion in  0.4  per  cent,  sodium  chloride  with  5  drops  of  adrenalin  chloride 
solution,  i  :  1000  to  each  ounce.  The  anesthesia  has  been  complete 


LOCAL   ANESTHETICS  97 

in  all  cases  and  has  invariably  lasted  in  excess  of  an  hour.  No 
immediate  or  late  irritating  effect  was  noted  and  the  wounds  healed  as 
well  as  after  the  use  of  any  other  anesthetic  solution.  No  toxic  or 
other  unpleasant  immediate  or  after-effects  were  noted,  although, 
large  quantities  were  purposely  used  to  determine  this  point;  as  much 
as  4  ounces  in  one  case,  which  represented  nearly  10  gr.  of  the  drug. 
This  limited  experience,  with  the  absence  of  other  data,  is  not  suffi- 
cient to  give  it  its  proper  place  among  local  anesthetic  agents.  Data 
regarding  its  toxicity  is  not  obtainable,  but  from  my  experience  it 
must  be  very  low.  In  this  connection,  the  manufacturers  state  that 
its  toxicity  is  not  greater  than  that  of  novocain  and  considerably  less 
than  that  of  other  anesthetics  commonly  employed. 

I  have  not  been  able  to  obtain  any  more  exact  information  than 
the  above  and  the  time  at  my  disposal  does  not  permit  of  further 
observation. 

The  following  are  the  results  of  injections  made  upon  myself  in 
studying  its  action.  The  preparation  experimented  with  was  in 
liquid  form  put  up  with  a  saturated  solution  of  chloretone  for  pur- 
poses of  preservation,  which  I  believe  is  a  mistake  as  noted  later. 
The  solution  was  first  boiled  for  ten  minutes.  Intradermal  wheals 
were  made  in  my  skin  at  various  points,  using  for  each  injection  i 
c.c.  of  solution. 

1.  One  per  cent,  of  apothesine,  injection  9. 55  P.M.,  slight  negligible 
burning  if  injected  too  rapidly,  which  immediately  subsided;  no  sen- 
sation if  slowly  injected.     Immediate  anesthesia.     Within  about  ten 
minutes  slightly  pale  area  had  developed  around  wheal  and  center 
became  slightly  pink.     After  fifteen  to  twenty  minutes  slight  itch- 
ing sensation.     10.30  P.M.,  pink  center  has  become  more  marked. 
1 1. 10,  anesthesia  still  complete.     11.25,  returning  sensation.     11.55, 
nearly  normal  sensation.     12.30  not  yet  quite  normal.     Complete 
anesthesia  for  one  hour  fifteen  minutes.     Pink  center  to  wheal  still 
persists  with  a  very  slight  suggestion  of  infiltration  in  surrounding 
tissues. 

2.  One  per  cent,  apothesine,  5  drops  of  adrenalin,  i  :  1000  to  the 
ounce,  injection  10.02,  results  similar  to  last  injection,  except  that 
pale  area  surrounding  wheal  was  slightly  more  marked,  with  pink 
center  more  pronounced. 

12.15,  anesthesia  still  complete.  12.30,  returning  sensation. 
Complete  anesthesia  one  hour  fifteen  minutes.  Subsequent  appear- 
ance of  area  same  as  with  i  per  cent,  without  the  adrenalin. 

3.  One-half    per    cent,    apothesine,    sodium    chloride,    0.4    per 


98  LOCAL   ANESTHESIA 

cent.;  injection  10.07,  no  sensation  during  injection.  Immediate 
anesthesia.  Pink  center  and  pale  surrounding  area  as  with  other 
injections.  10.35,  complete  anesthesia.  10.40,  returning  sensation. 
10.45,  nearly  normal,  n  o'clock,  normal.  Thirty  minutes,  com- 
pletes anesthesia. 

4.  One-half  per  cent,  of  apothesine,  adrenalin  solution  i  :  1000,  5 
drops  to  the  ounce.     Injection,  u  o'clock.     Immediate  anesthesia. 
Appearance  same  as  above.     Forty-five  minutes,  complete  anesthesia. 

5.  One-half  per  cent,  apothesine,  sodium  chloride,  0.4  per  cent., 
adrenalin  solution,  i  :iooo,  5  drops  to  the  ounce.     Injection,  10.13. 
11.30,    complete    anesthesia.     11.37,    returning    sensation.     11.50, 
nearly    normal.     Complete   anesthesia  one   hour  fifteen  minutes. 
Appearance  of  injected  area  same  as  above. 

6.  One-fourth  per  cent,  apothesine,  injection,  10.33.     No  sensa- 
tion.    Immediate  anesthesia.     10.55,  complete  anesthesia.     11.05, 
returning  sensation.     11.15,  nearly  normal.     11.28,  normal.     Pink 
center  and  pale  surrounding  area  less  marked  than  with  the  stronger 
solutions. 

7.  One-fourth  per  cent,  apothesine,  0.4  per  cent,  sodium  chloride, 
injection,  10.38.     No  sensation.     11.15,  complete  anesthesia.     II-I9> 
returning  sensation.     11.35,  nearly  normal.     11.50,  normal.     Thirty- 
seven    minutes    complete    anesthesia.     After-appearance    same    as 
above. 

8.  One-fourth  per  cent,  apothesine,  adrenalin  solution  i  :  1000, 
5  drops  to  ounce.     Injection,  n  o'clock.     11.40,  complete  anesthesia. 
11.45,    returning   sensation.     Forty   minutes   complete    anesthesia. 
After-appearance  same  as  above. 

9.  One-fourth  per  cent,  apothesine,  0.4  per  cent,  sodium  chloride, 
adrenalin  solution  i  :  1000,  5  drops  to  ounce.     Injection,  1 1.13.     1 1 .50 
complete  anesthesia.     12  o'clock,  returning  sensation.     12.35,  nearly 
normal.     Thirty-seven  minutes  complete  anesthesia. 

The  next  day,  a  slightly  reddish  punctate  spot  marks  the  site  of 
the  wheals.  This  is  more  marked  in  those  in  which  the  stronger 
solutions  have  been  used  and  slightly  more  so  where  adrenalin  had 
been  added.  Slight  soreness  and  itching  present  in  all  spots  when 
manipulated,  but  not  noticeable  without  manipulation.  In  the  two 
i  per  cent,  injections  a  very  slight  infiltration  of  the  tissues  notice- 
able. The  frequent  examination  of  the  areas  in  which  they  were 
stuck  by  a  needle  every  few  minutes  during  the  period  of  the  examina- 
tion, should  be  considered  in  drawing  conclusions  from  their  appear- 
ance. The  anesthesia  in  all  cases  was  immediate  and  complete  and 


LOCAL   ANESTHETICS  99 

disappeared  very  slowly.  It  was  often  longer  than  one-half  hour 
from  the  time  returning  sensation  was  first  noted  until  it  appeared 
normal.  The  pink  appearance  in  the  center  of  the  wheal  in  the  case 
of  the  stronger  solutions,  persisted  for  forty-eight  hours,  but  no  simi- 
lar reaction  had  been  noticed  in  the  clinical  use  of  the  drug,  although 
the  wound  had  been  closely  watched.  To  determine  the  cause  of 
this  reaction,  two  injections  were  made  into  my  skin  with  solutions, 
prepared  by  tablets  of  the  same  drug  which  did  not  contain  chloretone. 
In  each  case  there  was  no  sensation  during  the  injection  and  the  cen- 
tral pink  area  and  surrounding  pale  areola  were  less  marked  and  dis- 
appeared after  a  few  hours.  Otherwise,  the  resulting  anesthesia  and 
its  duration  were  the  same.  The  site  of  injection,  if  disturbed  by 
manipulation,  gave  a  slight  itching  sensation,  otherwise,  it  was  not 
noticeable. 

To  test  the  effect  of  chloretone  when  injected  alone,  I  injected  my 
forearm  with  10  minims  of  a  saturated  solution  of  chloretone,  0.8 
per  cent.,  the  same  strength  with  which  the  apothesine  is  put  up; 
slight  burning  occurred  if  injected  too  rapidly.  When  tested  with  a 
point  of  a  needle  for  anesthesia,  it  was  found  to  be  completely  anes- 
thetic only  in  the  center  of  the  wheal  and  wherever  the  needle  was 
entered,  a  red  punctate  spot  appeared  immediately  and  remained 
permanently.  Otherwise,  the  wheal  presented  no  change  in  appear- 
ance from  the  surrounding  tissue.  Anesthesia  lasted  about  forty 
minutes  only  in  the  center;  the  periphery  quickly  returning  to  normal. 

I  am  consequently  forced  to  the  conclusion  that  much  of  the  after- 
appearance  of  the  injected  areas  in  these  experiments  must  be  due 
to  the  presence  of  chloretone  in  the  solution  and  accordingly  suggest 
that  this  method  of  preparing  the  solution  be  changed,  as  it  probably 
will,  and  the  drug  marketed  in  powder  form,  as  is  the  case  with  other 
local  anesthetics. 

In  conclusion,  I  wish  to  state  that  I  feel  this  preparation  has  a 
decidedly  useful  future  and  should  be  given  a  fair  and  impartial  trial. 
In  my  own  observation  it  compares,  at  least  in  its  anesthetic  pro- 
ducing properties  and  its  low  degree  of  toxicity,  very  favorably  with 
novocain. 

COMPARATIVE  ACTION  OF  ANESTHETIC  AGENTS 

The  most  thorough  and  careful  investigation  of  the  comparative 
action  of  the  different  anesthetic  agents  and  their  relative  toxicity 
has  been  undertaken  by  Piquand  and  Dreyfus.  Their  first  investiga- 


100  LOCAL  ANESTHESIA 

tion  was  on  the  toxicity  of  different  mixtures  of  cocain  and  stovain, 
and  was  undertaken  in  1907  and  reported  to  the  Society  de  Biologic. 
In  this  investigation  rabbits  and  guinea-pigs  were  used,  and  the  in- 
jections slowly  and  uniformly  made  in  all  cases. 

The  following  are  the  results  of  these  investigations: 

INTRAVENOUS  INJECTIONS  IN  RABBITS 
Stovain: 

Rabbit,  3  kg.  (0.150),  death  with  9  eg.  (0.5),  or  0.0301  per  kilo  of  animal. 
Rabbit,  2  kg.  (0.870),  death  with  8  eg.  (0.5),  or  0.0299  per  kilo  of  animal. 

Cocain : 

Rabbit,  2  kg.  (0.975),  death  with  4  eg.,  or  0.0168  per  kilo  of  animal. 

Rabbit,  2  kg.  (0.850),  death  with  5  eg.  (0.5),  or  0.0192  per  kilo  of  animal. 
Rabbit,  3  kg.  (o.  150),  death  with  6  eg.,  or  0.019    per  kilo  of  animal. 

Stovain  (%),  cocain,  i  part  to  200  dilution: 

Rabbit,  3  kg.  (o.  150),  death  with  8  eg.,  or  0.0266  per  kilo  of  animal. 

Rabbit,  3  kg.  (o.  150),  death  with  Q  eg.,  or  0.0285  Per  kilo  of  animal. 

Rabbit,  2  kg.  (0.500),  death  with  7  eg.  (0.5),  or  0.03     per  kilo  of  animal. 

Stovocain  and  cocain,  each  i  to  200: 

Rabbit,  i  kg.  (0.900),  death  with  4  eg.  (o.  25),  or  0.025  per  kilo  of  animal. 
Rabbit,  i  kg.  (0.930),  death  with  6  eg.,  or  0.031  per  kilo  of  animal. 

Rabbit,  i  kg.  (0.870),  death  with  5  eg.,  or  0.026  per  kilo  of  animal. 

INTRAPERITONEAIJ,  INJECTIONS  IN  THE  GUINEA-PIG 
Cocain : 

Guinea-pig,  620  grams,  death  with  5  eg.  (0.2),  or  8  eg.  (0.3)  per  kilo  of  animal. 
Guinea-pig,  600  grams,  survived  with  4  eg.  (0.5),  or  7  eg.  (0.5)  per  kilo  of  animal. 
Guinea-pig,  730  grams,  survived  with  6  eg.,  or  8  eg.  per  kilo  of  animal. 

Stovain: 

Guinea-pig,  420  grams,  survived  with  8  eg.,  or  19  eg.  per  kilo  of  animal. 

Guinea-pig,  520  grams,  survived  with  9  eg.,  or  17  eg.  per  kilo  of  animal. 

Guinea-pig,  430  grams,  death       with  8  eg.  (0.5),  or  19  eg.  per  kilo  of  animal. 

Stovain  (%),  cocain,  i  part  to  200  dilution: 

Guinea-pig,  400  grams,  death       with  9  eg.,  or  22  eg.  (0.5)  per  kilo  of  animal. 

Guinea-pig,  700  grams,  survived  with  9  eg.,  or  12  eg.  (0.5)  per  kilo  of  animal. 

Guinea-pig,  540  grams,  death  with  9  eg.  (0.2),  or  17  eg.  per  kilo  of  animal. 
Guinea-pig,  510  grams,  survived  with  7  eg.  (0.75),  or  15  eg.  per  kilo  of  animal. 
Guinea-pig,  480  grams,  survived  with  7  eg.  (0.75),  or  16  eg.  per  kilo  of  animal. 

Stovain  and  cocain,  each  i  part  to  200: 

Guinea-pig,  930  grams,  survived  with  12  eg.  (0.5),  or  13  eg.  per  kilo  of  animal. 
Guinea-pig,  700  grams,  death  with  10  eg.  (0.5),  or  15  eg.  per  kilo  of  animal. 

It  will  be  seen  from  a  careful  perusal  of  the  foregoing  that  stovain 
is  about  three-fourths  as  toxic  as  cocain,  at  least  for  the  smaller  ani- 
mals, and  that  by  using  mixtures  of  the  stovain  and  cocain  that  much 


LOCAL   ANESTHETICS  IOI 

larger  total  quantities  could  be  used  than  would  have  been  the  case 
with  either  agent  alone.  This  last  point  is  of  practical  interest  in 
bearing  out  Burgi's  contention  spoken  of  elsewhere  in  this  book,  and 
made  use  of  by  Schleich,  who  now  combines  alypin  with  cocain  in 
equal  quantities  in  all  his  local  anesthetic  solutions. 

The  following  is  drawn  from  investigations  by  the  same  authors 
(Piquand  and  Dreyfus),  and  appeared  in  the  "Jour.  Phys.  et  Path. 
Gen.,"  for  January,  1910: 

"Comparing  cocain  with  stovain  on  peripheral  nerves  and  on  the 
cornea  of  animals  they  found  that  in  the  same  strength  and  quanti- 
ties stovain  was  slower  in  action  and  of  shorter  duration  than  cocain — 
twenty  minutes  as  compared  to  twenty-five. 

"Comparing  tropococain  with  alypin  in  the  eye  of  animals,  it  was 
found  that  with  equal  quantities  of  the  same  strength  solution  alypin 
was  slightly  slower  in  action  and  of  somewhat  longer  duration  than 
tropococain- — twenty  minutes  as  compared  to  fifteen.  The  eye 
treated  with  alypin  was  slightly  inflamed  for  forty-eight  hours 
afterward. 

"Comparing  cocain  with  stovain  injected  intradermally  gave 
about  the  same  comparative  results  as  when  used  on  peripheral 
nerves  or  in  the  cornea.  Comparing  tropococain  with  alypin  intra- 
dermally, tropococain  anesthesia  (i  per  cent.)  takes  place  immedi- 
ately and  persists  nineteen  to  twenty  minutes. 

"Alypin  (i  per  cent.)  anesthesia  at  the  end  of  two  to  three 
minutes,  and  lasted  twenty  to  twenty-two  minutes,  the  skin  re- 
maining red  and  painful  for  several  hours  afterward. 

"Novocain  (i  per  cent.)  gave  immediate  complete  anesthesia  for 
twenty  minutes.  Novocain  (5  per  cent.),  with  i  drop  of  adrenalin 
solution  (i  per  cent,  per  cubic  centimeter),  gave  an  immediate  anes- 
thesia with  anemia  that  persisted  a  very  long  time.  At  the  end  of 
one  hour  the  skin  was  insensitive  to  pricking  and  pinching. 

"In  clinical  use  cocain  (i  :  200)  in  Reclus'  solution  produced  anes- 
thesia after  two  to  three  minutes,  lasting  fifty  to  sixty  minutes;  i 
per  cent,  solution  gave  an  anesthesia  lasting  eighty  to  ninety  minutes. 

"In  less  concentrated  solutions  (i  1400)  anesthesia  was  obtained 
in  six  to  seven  minutes,  but  often  incomplete,  its  effect  passing  off 
after  twenty  to  thirty  minutes;  i  :  1000  solution,  as  recommended  by 
Schleich,  gave  unsatisfactory  results. 

"Solution  i  :  200  when  kept  in  prolonged  contact  with  mucous 
membranes  produced  anesthesia.  Stovain  in  clinical  use  in  equal 
strength  as  cocain  was  found  to  be  less  effective  and  of  shorter  dura- 


102  LOCAL  ANESTHESIA 

tion.  M.  Billon  found  0.75  per  cent,  solution  of  stovain  equal  to 
0.5  per  cent,  solution  of  cocain. 

"Stovain  in  pure  watery  solutions  was  often  found  to  be  painful 
and  the  development  of  anesthesia  somewhat  delayed;  in  physiologic 
salt  solution  its  action  was  more  prompt. 

"To  augment  the  degree  and  duration  of  the  action  of  the  stovain 
solution  Billon  recommends  either  the  combination  with  cocain  or 
alcohol: 

Alcohol  (90  per  cent.) 20  c.c. 

Aq.  dest 75  c.c.  (0.05) 

Stovain (o .  50) 

Anesthesia  produced  by  this  solution  is  superior  to  that  of  stovain 
in  pure  watery  solutions,  but  clearly  inferior  to  cocain  in  0.5  per  cent, 
solutions. 

"  Clinical  experiments  with  beta-eucain  showed  it  to  be  less  active 
and  of  shorter  duration  than  that  produced  by  cocain. 

"In  clinical  experiments  tropococain  was  found  to  produce  a 
slightly  longer  anesthesia  than  stovain.  Novocain  was  found  to  pos- 
sess anesthetic  properties  superior  to  stovain  and  tropococain  and 
almost  equal  to  cocain.  In  pure  watery  solution  of  5  per  cent,  it  was 
very  slightly  painful,  but  not  at  all  so  in  normal  salt  solution — its 
anesthesia  was  of  short  duration,  about  twenty-five  minutes. 

"In  two  patients  operated  upon  in  which  one-half  the  field  was 
anesthetized  with  cocain  and  the  other  half  with  novocain,  each  i  :  200 
solution,  the  following  observations  were  made:  The  injection  of  each 
was  painless;  in  the  fields  infiltrated  with  cocain  the  anesthesia  ap- 
peared slightly  quicker  than  the  half  infiltrated  with  novocain;  in 
one  there  was  no  difference  in  the  intensity  of  the  anesthesia;  in  the 
other  there  was  a  slight  difference  in  favor  of  cocain;  in  each  the 
anesthesia  was  slightly  longer  in  the  cocain  half  of  the  fields. 

"In  several  patients  anesthetized  partly  with  stovain  and  partly 
with  novocain,  each  i  :  200  solution,  the  injections  of  stovain  were 
always  slightly  painful,  while  the  novocain  injections  were  always 
painless,  more  rapid  and  more  complete  in  action,  but  the  stovain 
anesthesia  was  maintained  slightly  longer. 

"Two  patients  anesthetized  partly  with  novocain  and  partly  with 
cocain-stovain  (in  equal  parts)  each  presented  a  perfect,  complete 
anesthesia,  but  more  durable  in  the  cocain-stovain  field. 

"A  patient,  anesthetized  one-half  the  field  with  novocain  and  the 
other  half  with  tropococain  i  :  200,  presented  an  anesthesia  more 
complete  with  novocain,  but  more  durable  with  tropococain." 


LOCAL   ANESTHETICS  103 

To  augment  the  durability  of  novocain  anesthesia,  Reclus  has 
suggested  the  following: 

"  Normal  salt  solution 100  grams 

Novocain 50  centigrams 

Adrenalin  (i :  1000  solution) 25  drops 

With  this  mixture,  in  an  experience  of  over  300  cases,  anesthesia  was 
immediate,  complete,  and  lasted  in  general  over  an  hour." 

The  comparative  value  of  the  agents  experimented  with  is  given 
as  follows: 

1.  Cocain,  the  most  efficient. 

2.  Novocain-adrenalin,  nearly  equal  in  power  to  cocain,  but  more 
durable. 

3.  Novocain,  alypin,  and  coca-stovain  in  equal  parts;  these  three 
have  an  anesthetic  power  nearly  equal  but  less  durable  for  novocain. 

4.  S  to  vain,  tropococain,  beta-eucain;  these  three  about  equal. 
They  hold  the  same  general  opinion  as  all  experienced  observers, 

namely,  that  the  toxicity  of  cocain  and  its  substitute  depends  upon 
the  concentration  of  the  solution  and  the  rapidity  with  which  it  is 
injected  and  taken  into  the  general  circulation.  The  same  dose  that 
will  kill  an  animal  when  injected  intravenously  in  concentrated  solu- 
tion can  be  given  subcutaneously  in  dilute  solution  without  noticeable 
ill  effects;  or,  if  injected  in  concentrated  solution  and  its  absorption 
delayed  through  constriction,  its  toxic  action  is  weakened  propor- 
tionate to  the  delay. 

"i.  By  injecting  into  the  vein  of  a  rabbit  weighing  2  kg.  (0.330) 
a  solution  of  cocain  i  :  200  in  such  a  way  as  to  control  the  flow  to 
5  c.c.  per  minute,  the  animal  died  when  it  had  received  15  eg.  of  the 
alkaloid  or  6  eg.  (0.4)  per  kilogram  of  weight. 

"2.  By  increasing  the  flow  to  10  c.c.  per  minute  in  a  rabbit 
weighing  9  kg.  (0.130)  death  occurred  when  it  had  received  9  eg.  of 
the  alkaloid  or  4  eg.  (0.2)  per  kilogram  of  weight. 

"3.  By  diminishing  the  flow  to  5  c.c.  per  two  minutes  in  a  rabbit 
weighing  3  kg.  (0.200)  death  occurred  when  the  animal  had  received 
20  eg.  of  the  alkaloid  or  9  eg.  per  kilogram. 

"  Similar  experiences  were  had  with  cocain,  stovain,  and  tropo- 
cocain, and  demonstrates  the  law  given  by  Reclus  that  the  toxicity 
of  the  drug  depends  upon  the  quantity  introduced  into  the  circula- 
tion and  reaching  the  central  nervous  system  at  the  same  time. 

"By  administering  the  drug  in  interrupted  doses  or  by  delaying 
its  absorption  it  is  possible  to  administer  three  or  four  times  the  toxic 
dose  without  injury. 


IO4  LOCAL  ANESTHESIA 

TOXICITY 

"All  injections  were  made  in  the  vein  on  the  ear  of  the  rabbit, 
using  solutions  of  i :  200  strength,  with  the  Roger  apparatus,  which 
regulated  the  flow  to  5  c.c.  per  minute. 

1.  Cocain: 

Rabbit,  2  kg.  (0.975),  death  with  4  eg.,  or  0.0168  per  kilo  of  animal. 

Rabbit,  2  kg.  (0.850),  death  with  5  g.  (0.5),  or  0.0192  per  kilo  of  animal. 
Rabbit,  3  kg.  (o.  150),  death  with  6  eg.,  or  0.019  Per  kilo  of  animal. 

2.  Stovain: 

Rabbit,  3  kg.  (o.  150),  death  with  9  eg.  (0.5),  or  0.0301  per  kilo  of  animal. 
Rabbit,  2  kg.  (0.870),  death  with  8  eg.  (0.5),  or  0.0299  Per  kilo  of  animal. 
Rabbit,  2  kg.  (0.300),  death  with  8  eg.  (0.7),  or  0.030  per  kilo  of  animal. 

3.  Stovain-cocain  (%),  i  to  200. 

Rabbit,  3  kg.,  death  with  8  eg.,  or  o.  266    per  kilo  of  animal. 

Rabbit,  3  kg.  (o.  150),  death  with  9  eg.,  or  0.0285  per  kilo  of  animal. 

Rabbit,  2  kg.  (0.500),  death  with  7  eg.   (0.5),  or  0.03      per  kilo  of  animal. 

4.  Stovain-cocain,  each  i  to  200: 

Rabbit,  i  kg.  (o.  700),  death  with  4  eg.  (o.  25),  or  0.025  Per  kilo  of  animal. 
Rabbit,  i  kg.  (0.930),  death  with  6  eg.,  or  0.031  per  kilo  of  animal. 

Rabbit,  i  kg.  (0.870),  death  with  5  eg.,  or  0.026  per  kilo  of  animal. 

5.  Beta-eucain: 

Rabbit,  2  kg.  (0.900),  death  with  5  eg.  (0.5),  or  0.0187  per  kilo  of  animal. 
Rabbit,  2  kg.  (0.800),  death  with  5  eg.  (0.5),  or  0.0196  per  kilo  of  animal. 

6.  Tropococain: 

Rabbit,  2  kg.  (0.900),  death  with  5  eg.  (0.8),  or  0.02    per  kilo  of  animal. 
Rabbit,  3  kg.  (o.  100),  death  with  6  eg.,  or  0.019  Per  kilo  of  animal. 

Rabbit,  2  kg.  (0.800),  death  with  6  eg.  (o.  i),  or  0.022  per  kilo  of  animal. 

7.  Alypin: 

Rabbit,  2  kg.  (0.600),  death  with  4  eg.  (0.5),  or  0.0155  per  kilo  of  animal. 
Rabbit,  2  kg.  (0.850),  death  with  5  eg.,  or  0.0178  per  kilo  of  animal. 

Rabbit,  3  kg.  (0.050),  death  with  5  eg.  (0.5),  or  0.0182  per  kilo  of  animal. 

8.  Novocain: 

Rabbit,  2  kg.  (0.330),  death  with  15  eg.,  or  0.064  per  kilo  of  animal. 

Rabbit,  2  kg.  (0.328),  death  with  15  eg.  (  0.5),  or  0.066  per  kilo  of  animal. 
Rabbit,  2  kg.  (0.380),  death  with  14  eg.  (0.5),  or  0.06  per  kilo  of  animal. 

9.  Novocain  (i  to  200)  and  i  drop  of  adrenalin  solution  (1:1000)  per  2  c.c.: 
Rabbit,  2  kg.  (.150),  death  with  20  c.c.  of  the  sol.,  or  4cg.  (.6)  of  novocain 
per   kilo  of  animal. 

Rabbit,  i  kg.  (.950),  death  with  17  c.c.  of  the  sol.,  or  4cg.  (.6)  of  novocain 

per  kilo  of  animal. 

Rabbit,  2  kg.  (.250),  death  with  25  c.c  .of  the  sol.,  or  scg.  (.1)  of  novocain 

per  kilo  of  animal. 

Rabbit,  2  kg.  (.100),  death  with  20  c.c.  of  the  sol.,  or  4  eg.  (.7)  of  novocain 

per  kilo  of  animal. 


LOCAL   ANESTHETICS  105 

10.  From  the  above  the  following  relative  averages  of  toxicity  were  obtained: 
i  eg.  (0.7)    per  kilo  of  animal  for  alypin. 
i  eg.  (o .  83)  per  kilo  of  animal  for  cocain. 

1  eg.  (o .  9)    per  kilo  of  animal  for  beta-eucain. 

2  eg.  per  kilo  of  animal  for  tropococain. 

2  eg.  (0.7)    per  kilo  of  animal  for  stovian  and  cocain  equal  parts.' 

2  eg.  (0.83)  per  kilo  of  animal  for  stovain  and  cocain  (%  parts). 

3  eg.  per  kilo  of  animal  for  stovain. 

4  eg.  (0.6)    per  kilo  of  animal  for  novocain-adrenalin. 
6  eg.  (0.3)    per  kilo  of  animal  for  novocain. 

INTRAPERITONEAL  TOXICITY  IN  THE  GUINEA-PIG 

1 .  Cocain,  i  per  cent. : 

Guinea-pig,  620  grams,  survived  with  5  eg.  (0.2),  or  8  eg.  (0.3)  per  kilo  of  animal. 
Guinea-pig,  600  grams,  survived  with  4  eg.  (0.5),  or  7  eg.  (0.5)  per  kilo  of  animal. 
Guinea-pig,  730  grams,  survived  with  6  eg.,  or  8  eg.  per  kilo  of  animal. 

2.  Stovain,  i  per  cent. 

Guinea-pig,  420  grams,  survived  with  8  eg.,          or  19  eg.        per  kilo  of  animal. 
Guinea-pig,  520  grams,  survived  with  8  eg.,  or  17  eg.         per  kilo  of  animal. 

Guinea-pig,  430  grams,  death       with  8  eg.,          or  19  eg.        per  kilo  of  animal. 

3.  Stovain  and  cocairl  (%),  i  per  cent. : 

Guinea-pig,  700  grams,  survived  with  9  eg.,  or  12  eg.  (0.5)  per  kilo  of  animal. 

Guinea-pig,  540  grams,  death  with  9  eg.  (0.2),  or  17  eg.  per  kilo  of  animal. 
Guinea-pig,  510  grams,  survived  with  7  eg.  (0.75),  or  15  eg.  per  kilo  of  animal' 
Guinea-pig,  480  grams,  survived  with  7  eg.  (0.75),  or  16  eg.  per  kilo  of  animal. 

4.  Stovain  and  cocain,  each  i  per  cent. : 

Guinea-pig,  930  grams,  survived  with  12  eg.  (0.5),  or  13  eg.  per  kilo  of  animal. 

Guinea-pig,  700  grams,  death       with  10  eg.  (0.5),  or  15  eg.  per  kilo  of  animal. 

Guinea-pig,  700  grams,  death       with  10  eg.  (0.5),  or  15  eg.  per  kilo  of  animal. 

Guinea-pig,  570  grams,  survived  with    7  eg.  (0.5),  or  13  eg.  per  kilo  of  animal. 

5.  Novocain,  i  per  cent.: 

Guinea-pig,  595  grams,  with  19  eg.  per  kilo  showed  no  trouble. 
Guinea-pig,  357  grams,  with  20  eg.  per  kilo  showed  no  trouble. 
Guinea-pig,  362  grams,  with  30  eg.  per  kilo  showed  no  trouble. 
Guinea-pig,  372  grams,  with  40  eg.  per  kilo  showed  no  trouble. 
Guinea-pig,  550  grams,  with  50  eg.  per  kilo  became  very  ill. 
Guinea-pig,  350  grams,  with  60  eg.  per  kilo,  death. 
Guinea-pig,  510  grams,  with  50  eg.  per  kilo,  death. 

6.  Novocain-adrenalin  (i  per  cent.)  with  i  drop  of  adrenalin  (1:1000)  per  2  c.c.: 
Guinea-pig,  360  grams,  with  30  eg.  per  kilo  showed  no  trouble. 
Guinea-pig,  375  grams,  with  40  eg.  per  kilo  showed  no  trouble. 
Guinea-pig,  420  grams,  with  45  eg.  per  kilo  became  ill. 

Guinea-pig,  500  grams,  with  50  eg.  per  kilo,  death. 

"From  the  above  experiments  the  following  comparisons  were 
drawn  for  the  relative  toxicity  of  intraperitoneal  injections: 


106  LOCAL   ANESTHESIA 

8  eg.  (0.15)  per  kilo  of  animal  for  cocain. 
14  eg.  per  kilo  of  animal  for  cocain-stovain 

16  eg.  (0.5)    per  kilo  of  animal  for  cocain-stovain  (%). 
19  eg.  per  kilo  of  animal  for  stovain. 

50  eg.  per  kilo  of  animal  for  novocain. 

SP  eg.  per  kilo  of  animal  for  novocain-adrenalin,  25  drops. 

"  Novocain  was  almost  three  times  less  toxic  than  stovain  and 
six  times  less  toxic  than  cocain.  What  was  particularly  important 
was  that  novocain-adrenalin  was  notably  more  toxic  than  novocain 
alone  only  in  intravenous  injection,  but  was  not  more  toxic  in  intra- 
peritoneal  injection. 

"Subcutaneous  injections  on  various  animals  show  that  novocain- 
adrenalin  is  not  appreciably  more  toxic  than  novocain  alone. 

"Action  on  the  Tissues. — Cocain  when  injected  into  the  tissues 
causes  no  pain  or  inflammation  and  is  absorbed  without  leaving  be- 
hind any  trace  of  its  action.  When  instilled  into  the  eye  it  causes 
no  pain  or  alteration  in  the  cornea.  It  has  a  marked  vasoconstrictor 
action. 

"Concentrated  solutions  when  instilled  into  the  eye  cause  a 
momentary  burning  pain.  This  is  more  marked  with  some  prepa- 
rations than  with  others,  and  is  probably  due  to  slight  differences  in 
the  method  of  manufacture. 

"Stovain  when  instilled  into  the  eye  causes  a  marked  sensation, 
as  of  a  foreign  body,  lacrimation,  and  photophobia,  the  vessels  be- 
coming injected  with  moderate  contraction  of  the  pupil.  Injected 
intradermally  and  subcutaneously  it  provokes  pain  lasting  two  to 
three  minutes. 

"The  lacrimation,  photophobia,  and  congestion  produced  by 
the  instillation  of  stovain  in  the  eye,  and  when  injected  into  the  tis- 
sues the  pain  and  vasodilatation  indicated  an  irritation  due  to  its 
acid  reaction." 

German  authors,  particularly  Braun,  insisted  upon  this  irritant 
action  of  stovain  and  cite  4  cases,  observed  by  Sinclair,  in  which  gan- 
grene of  the  tissues  followed  the  use  of  a  2  per  cent,  solution.  -But 
Reclus,  in  an  experience  of  over  3000  cases  with  stovain  in  1.5  per 
cent,  solution,  did  not  see  a  single  such  accident,  and  when  used  on 
the  dog  and  rabbit  in  10  and  15  per  cent,  solutions  did  not  see  a  trace 
of  gangrene.  Clinically,  it  produced  a  slight  irritation  of  moderate 
duration. 

"3.  Beta-eucain,  injected  subcutaneously,  causes  a  sharp  pain 
which  lasts  several  minutes.  Instilled  into  the  eye  it  causes  lacrima- 


LOCAL   ANESTHETICS  IO*J 

tion,  photophobia,  and  a  persistent  redness.  These  phenomena  of 
irritation  are  notably  more  marked  and  more  durable  than  with 
stovain. 

•"4.  Tropococain,  when  injected  into  the  tissues,  is  not  irritating, 
and  has  no  effect  upon  the  vessels.  Instilled  into  the  eye  of  the 
rabbit  it  causes  a  slight  lacrimation  and  redness  of  the  conjunctiva. 

"5.  Alypin  is  extremely  irritant;  intradermal  injection  of  i  per 
cent,  solution  are  painful,  and  accompanied  by  marked  redness  and 
vasodilatation.  Following  the  injections  the  tissues  remain  painful 
and  infiltrated  for  a  long  time.  Five  per  cent,  solutions  are  ex- 
tremely painful,  and  may  be  followed  by  gangrene.  Instilled  into 
the  eye  in  5  per  cent,  solutions  causes  pain,  lacrimation,  photophobia, 
redness  of  the  conjunctiva,  and  transient  paralysis  of  accommodation. 

"6.  Novocain  does  not  appear  at  all  irritant;  with  injections  of 
0.5  or  i  per  cent,  there  is  no  vasoconstriction  or  vasodilatation  and 
leaves  no  after-effect  upon  the  tissues.  Injections  of  10  per  cent,  are 
slightly  irritant  and  produce  slight  congestion  of  the  tissues;  this 
rapidly  disappears  and  does  not  leave  behind  any  appreciable  lesion. 
Applied  to  the  mucous  membranes  on  tampons  it  produces  a  rapid 
anesthesia  without  any  disturbing  effects  upon  the  tissues.  When 
instilled  into  the  eye  it  causes  no  disturbance;  if  a  little  of  the  pure 
drug  is  dropped  on  the  cornea  it  causes  a  slight  irritation  of  short 
duration;  if  pure  cocain  is  dropped  on  the  cornea  it  produces  pro- 
nounced disturbances. 

"7.  Novocain  and  adrenalin  (1:200  with  i  drop  of  adrenalin 
solution  i :  1000  to  each  2  c.c.)  do  not  appear  to  be  more  irritating 
than  novocain  alone,  and  cause  no  disturbance  either  at  the  time  of 
the  injection  or  afterward.  With  the  adrenalin  it  produces  prolonged 
anesthesia  and  a  pronounced  vasoconstriction,  lasting  for  several 
hours.  These  conclusions  were  drawn  from  an  experience  of  over 
300  cases.  In  this  series  there  was,  however,  3  cases  of  gangrene, 
which  occurred  during  a  change  of  staff,  and  it  is  presumed  was  due  to 
some  error  in  the  technic  of  sterilization  or  preparation  of  the  fluid,  as 
no  similar  cases  had  been  reported  except  2  cases  by  Strohe  ("Deut- 
sche Zeit.  f.  Chir.,"  T.  x,  C.  T.  x,  p.  264),  but  in  these  2  cases  the 
quantity  of  adrenalin  was  very  large. 

"From  the  above  observations  the  following  conclusions  were 
drawn.  Cocain  is  the  most  powerful  of  all  local  anesthetics,  but  its 
high  toxicity  renders  it  dangerous;  a  safe  dose  should  not  exceed  14  to 
15  eg.  in  i :  200  solution,  care  being  taken  to  maintain  the  recumbent 
position  during  and  after  its  use. 


108  LOCAL  ANESTHESIA 

"Six  cases  of  death  occurred  from  the  use  of  cocain,  in  one  the 
dose  was  28  eg.  in  2  per  cent,  solution. 

"Beta-eucain  appears  to  present  no  advantage  over  cocain;  it  is 
equally  as  toxic,  much  less  anesthetic,  and  more  irritant. 

"  Alypin  should  be  proscribed  in  view  of  its  toxicity  and  irritating 
qualities. 

"Stovain  presents  considerable  advantage  over  cocain;  it  is  two 
times  less  toxic,  and  a  safe  dose  is  placed  at  30  eg.  of  a  i :  200  solution, 
but  this  dose  was  exceeded  several  times,  reaching  as  high  as  37  eg. 
without  observing  any  trouble.  Precautions  are  notably  less  im- 
portant than  with  cocain. 

"The  irritant  action  following  its  use  and  its  weaker  anesthetic 
power  can  be  largely  overcome  by  using  it  in  normal  salt  solution  and 
in  slightly  greater  strength. 

"  Tropococain.  Little  clinical  experience  was  had  with  this  alka- 
loid, but  it  appears  to  be  a  good  anesthetic.  Judging  from  the  experi- 
mental results,  its  toxicity  and  anesthetic  value  are  very  close  to 
that  obtained  with  stovain-cocain. 

"Novocain.  This  appears  at  the  present  time  the  most  com- 
mendable of  local  anesthetics;  its  feeble  toxicity  permits  large  doses 
to  be  used  without  inconvenience;  it  has  considerable  anesthetic 
power,  is  non-irritant,  and  not  a  vasodilator.  The  only  inconven- 
ience is  that  its  action  is  comparatively  a  little  shorter  than  cocain, 
but  this  can  be  overcome  by  the  addition  of  adrenalin,  which  pro- 
duces a  prolonged  anesthesia  of  slightly  more  marked  degree  without 
increasing  its  toxicity.  The  solution  that  has  given  the  best  results 
is  the  following,  recommended  by  Reclus: 

Normal  salt  solution 100  c.c. 

Novocain So  eg. 

Adrenalin  (i :  1000  solution) 25  drops." 

The  above  most  interesting  report,  which  covers  almost  the  entire 
range  of  local  anesthetics  as  employed  to-day,  will  bear  the  careful 
study  of  those  interested  in  working  out  any  problems  in  connection 
with  the  action  of  local  anesthetics. 

Some  interesting  points  worth  noting  are  the  increased  toxicity 
shown  when  novocain  was  administered  intravenously  with  adrena- 
lin. The  value  of  this  observation  is  lessened,  as  other  agents  were 
not  similarly  used  for  a  comparative  study,  and  leaves  us  to  draw  the 
only  likely  conclusion  that  the  increased  toxicity  was  due  to  the 
action  of  the  adrenalin  per  se,  and  not  to  the  fact  that  it  was  in  com- 
bination with  novocain. 


LOCAL   ANESTHETICS  IOQ 

Another  interesting  point  is  that  beta-eucain  is  given  a  toxicity 
equal  to  cocain ;  that  is,  however,  entirely  against  all  clinical  experi- 
ence, which  has  seemed  to  show  that  it  possessed  a  much  lower 
toxicity. 

Their  observations  regarding  the  irritant  action  and  toxicity  of 
alypin  are  decidedly  at  variance  with  the  German  school,  but  in 
this  respect  our  own  clinical  observations  are  more  nearly  in  line 
with  the  above. 

After  a  consideration  of  the  foregoing  table  it  is  seen  that  novocain 
possesses  advantages  unequaled  by  any  other  local  anesthetic,  being 
absolutely  non-irritant  and  six  to  seven  times  less  toxic  than  cocain, 
and,  when  in  combination  with  adrenalin,  producing  an  anesthesia 
that  for  intensity  and  duration  equals  that  obtained  by  any  other 
agent,  claims  sufficient  to  give  it  first  place  in  all  surgical  considera- 
tions, which,  combined  with  the  fact  that  it  forms  stable  solutions 
capable  of  repeated  boilings  without  deterioration,  make  it,  at  least 
for  the  present  time,  the  ideal  local  anesthetic. 

The  above  subject  was  similarly,  though  less  thoroughly,  studied 
by  the  Therapeutic  Committee  of  the  British  Medical  Association, 
who  arrived  at  nearly  similar  conclusions,  and  as  a  result  of  their 
studies,  have  fixed  the  following  scale  of  toxicity,  taking  cocain  as 
the  standard  of  comparison  and  having  it  represent  I : 

Alypin i .  25 

Cocain i .  oo 

Nirvanin o.  714 

Stovain .__ 0.625 

Tropococain o.  500 

Novocain 0.490 

Beta-eucain  lactate 0.414 

ANESTHETIC  PROPERTIES  OF  QUININ  SALTS 

Dr.  Griswold  of  Fredonia,  N.  Y.,  first  reported  the  local  anes- 
thetic action  of  quinin,  but  this  announcement  seemed  to  have  been 
forgotten  until  independently  discovered  by  Dr.  Henry  Thibault 
of  Scott,  Arkansas,  in  1907.  Prior  to  this  the  only  record  of  the  seda- 
tive action  of  quinin  is  a  report  by  Dr.  Fulton,  who  used  it  as  a 
local  application  to  the  nose  in  hay  fever  ("Jour.  Amer.  Med. 
Assoc.,"  July  20,  1904). 

The  hydrochlorid  of  quinin  and  urea,  which  was  first  discovered 
by  Driguine  in  1881,  and  extensively  used  all  over  the  world  as  the 
most  soluble  salt  of  quinin  and  the  best  adapted  to  hypodermic  use 
in  the  malarial  infections,  was  not  recognized  as  a  local  anesthetic 


110  LOCAL   ANESTHESIA 

until  many  years  later  when  attention  was  first  called  to  this  property, 
which  it  possesses  in  common  with  other  salts  of  quinin,  notably  the 
bisulphate.  In  this  the  analogy  of  historic  experience  is  not  unlike 
that  of  cocain. 

Dr.  Thibault  informs  me  that  he  discovered  the  anesthetic  prop- 
erties of  the  agent  while  administering  it  hypodermically  to  himself 
for  malaria  in  June,  1905,  by  taking  a  second  injection  six  hours  after 
the  first  in  the  same  place.  His  experiments  and  surgical  use  of  it 
quickly  followed,  which  he  reported  in  the  "Journal  of  the  Arkansas 
Medical  Society,  "  September  15,  1907. 

We  know  that  quinin  is  antiseptic,  antiperiodic,  antiphlogistic, 
antimiasmatic,  a  diminisher  of  reflex  action,  a  protoplasmic  poison, 
emmenagogue,  and  oxy toxic ;  we  have  now  to  add  its  anesthetic  prop- 
erties and  swell  the  list  of  its  already  many  uses. 

I  used  it  in  an  experimental  study  several  years  ago  in  33  cases, 
which  included  inguinal  hernia,  varicocele,  circumcision,  hemor- 
rhoids, anal  fissure,  fistula  in  ano,  superficial  abscesses,  ulcers  of  leg, 
epithelioma  of  face,  galactocele  of  breast,  and  removal  of  sebaceous 
cysts — a  fair  range  of  cases  and  sufficient  to  arrive  at  some  conclusion 
regarding  its  merits  as  a  local  anesthetic.  I  will  give  the  report  of 
my  observations  made  at  that  time. 

The  first  case  of  any  consequence  was  a  large  perirectal  abscess 
and  fistula  in  ano,  with  multiple  perirectal  sinuses.  It  was  a  trying 
case  for  any  form  of  local  anesthesia,  and  was  intended  to  put  the 
method  to  a  decided  test  and  develop  certain  technical  details  which 
I  had  found  necessary  from  my  experience  in  the  office. 

The  patient,  Burnell,  aged  sixty-seven,  was  operated  from  Ward  69,  Delgado  Memo- 
rial, December  2, 1909.  No  preliminary  morphin  or  sedatives  were  used.  A  i  per  cent, 
aqueous  solution  of  quinin  and  urea  hydrochlorid  was  selected.  The  injection  was  com- 
menced in  healthy  tissue  and  advanced  toward  the  inflamed  area.  The  initial 
injection  caused  some  burning  and  pain,  which  lasted  about  five  minutes.  By  advanc- 
ing slowly  into  the  surrounding  parts  practically  no  discomfort  was  caused,  no  more 
than  was  to  be  expected  from  the  manipulation  of  the  yet  unanesthetized  parts.  If  the 
infiltration  was  advanced  too  rapidly  it  produced  a  return  of  the  burning  pain  in  the 
freshly  invaded  area,  but  when  slowly  done  this  did  not  occur.  Also,  if  the  needle  was 
entered  too  near  the  margin  of  the  infiltrated  area,  without  waiting  for  anesthesia  to  be 
established,  it  caused  pain,  but  if  a  long  needle  was  used  and  entered  some  distance  back 
in  the  anesthetized  area  and  advanced  gradually  by  distending  the  tissues,  no  pain  was 
produced.  The  infiltration  process  lasted  fifteen  minutes,  and  by  the  time  it  was  com- 
plete the  area  first  injected  showed  profound  anesthesia;  those  last  injected  showed 
sensation  to  both  touch  and  pain. 

But  by  operating  in  the  order  of  the  infiltration,  by  the  time  the  area  last  infiltrated 
was  reached,  anesthesia  was  well  established.  The  infiltration  was  about  as  thorough  as 
would  have  been  obtained  with  any  other  local  anesthetic.  Several  injections  were  made 
deep  into  the  tissues  behind  and  to  the  side  of  the  anus  to  meet  the  branches  of  the  pudic 


LOCAL  ANESTHETICS  III 

nerve  as  they  came  down  from  the  spine  of  the  ischium.  In  all,  4  ounces  of  a  i  per  cent, 
solution  was  used,  19.2  gr.  of  quinin  salt.  The  anesthesia  produced  was  everywhere  pro- 
found. The  anus  was  dilated,  the  sinuses  slit  up  freely  and  curetted,  and  pieces  of  tissue 
removed. 

There  was  no  apparent  effect  on  the  circulation  in  situ;  there  was  considerable  bleed- 
ing and  hemostats  and  ligatures  were  used.  The  wound  was  finally  well  cleaned  and 
packed  freely. 

At  no  time  did  the  patient  suffer  any  discomfort  beyond  the  burning  pain  following 
the  first  injection. 

At  the  completion  of  the  operation  no  infiltration  of  the  tissues  was  apparent;  they 
presented  the  same  appearance  as  would  have  been  expected  after  a  general  anesthetic. 
No  peripheral  zone  of  hyperesthesia  could  be  detected. 

After  his  return  to  the  ward  observations  were  made  at  intervals  during  the  afternoon 
for  return  of  sensibility,  and  he  was  instructed  to  note  the  time  at  which  he  noticed  any 
painful  sensations  in  the  wound.  He  reported  next  day  that  there  had  been  no  painful 
Sensations,  but  a  feeling  of  deadness  about  the  operated  parts.  The  only  after-effect, 
either  local  or  general,  was  a  slight  ringing  in  the  ears  for  several  hours. 

The  wound  was  then  examined  and  the  pack  removed.  Infiltration  of  the  tissues 
was  now  very  apparent.  They  looked  and  felt  much  thickened  and  presented  a  pale, 
edemic,  grayish  appearance.  Two  striking  points  were  noticed.  The  removal  of  the 
pack  caused  no  pain  and  was  followed  by  very  little  oozing  of  blood.  This  was  in 
marked  contrast  to  what  would  have  been  expected  in  removing  a  pack  within  twenty- 
four  hours  from  a  wound  of  this  kind.  The  wound  was  dressed  daily  for  the  purpose  of 
making  observations,  and  very  little  change  noticed  from  day  to  day.  About  the  third 
day  the  tissues  in  the  wound  became  sensitive  to  the  prick  of  an  instrument  or  the  grasp 
of  a  dressing-forceps,  but  up  to  the  sixth  day  the  removal  of  the  pack  caused  no  pain. 
The  tissues  were  slow  in  losing  the  pale,  edemic  appearance,  and  some  infiltration  was 
still  noticed  eight  days  afterward.  The  progress  of  healing  seemed  much  retarded. 

Three  weeks  later,  when  the  patient  left  the  ward,  there  was  still  quite  a  wound, 
which  he  was  instructed  to  care  for.  He  returned  at  intervals  for  observation  and  it  was 
about  six  weeks  before  healing  was  complete. 

Through  the  kindness  of  Dr.  Matas,  I  was  permitted  to  operate, 
December  7,  1909,  on  a  galactocele  of  the  breast  of  sixteen  years' 
duration  in  Mrs.  M.,  aged  thirty-eight,  Ward  70,  Delgado  Memorial. 

The  operation  was  performed  in  the  general  amphitheater,  and  as  the  patient  was 
quite  nervous,  a  preliminary  injection  of  morphin,  %  gr.,  and  scopolamin,  J^50  gr.,  was 
given  a  short  time  before;  i  per  cent,  quinin  and  urea  in  sterile  water  was  used. 

The  first  injection  caused  some  little  burning  pain.  The  tissues  around  the  cyst  and 
at  the  base  of  the  gland  were  well  infiltrated.  A  large  incision  at  the  base  of  the  gland, 
under  its  dependent  portion,  was  then  made  and  the  breast  turned  up;  bleeding  was  very 
free;  the  cyst  was  dissected  out  and  its  ramifications  entirely  removed.  Aside  from  a 
little  nervousness  on  the  part  of  the  patinet,  she  made  no  complaint  and  the  procedure 
was  satisfactory. 

Six  ounces  of  the  solution  was  used,  28.8  gr.  of  the  quinin  salt.  The  wound  healed 
by  first  intention  without  much  apparent  infiltration  and  in  about  the  usual  time. 

On  January  3  I  attempted  to  operate  on  an  old  ulcer  of  the  leg,  the  result  of  a  com- 
pound fracture.  It  was  my  intention  to  curet  the  base  of  the  ulcer,  liberate  its  edges, 
and  draw  them  together. 

The  patient,  Mr.  B.,  aged  fifty-three,  a  railroad  conductor.  A  i  per  cent,  quinin  and 
urea  solution  was  used.  Infiltration  was  very  difficult,  as  the  tissues  everywhere  were 
much  thickened  and  bound  down  to  the  underlying  bones.  After  much  effort  at  infiltra- 


112  LOCAL  ANESTHESIA 

tion,  in  which  about  3  ounces  of  the  solution  was  used  and  a  delay  of  twenty  minutes  for 
anesthesia  to  become  established,  it  was  finally  abandoned,  as  the  tissues  seemed  as  sen- 
sitive as  at  first.  Cocain  was  then  used,  anesthesia  secured,  and  the  operation  performed. 

Inguinal  hernia:  Davis,  aged  thirty-three,  Ward  69.  Left  oblique  inguinal  hernia, 
duration,  four  years;  operation,  January  14,  1910,  i  per  cent,  quinin  and  urea. 

No  complaint  was  made  at  any  time  by  the  patient  and  anesthesia  was  very  satis- 
factory; 7  ounces  of  solution  were  used,  as  the  hernia  was  very  large.  By  the  time  the 
superficial  injection  of  the  skin  was  completed  anesthesia  was  established.  The  field  was 
very  vascular.  No  hyperesthesia  was  noted  and  no  induration  was  seen  at  the  comple- 
tion of  the  operation.  The  dressings  were  not  disturbed  for  one  week,  as  the  wound  had 
remained  perfectly  comfortable  and  the  ptaient  had  no  temperature. 

When  the  dressings  were  changed  the  wound  presented  a  brawny  induration,  ex- 
tending over  the  entire  area  of  infiltration;  the  tissues  were  much  thickened  and  felt 
leathery.  A  few  superficial  stitches  were  loosened  without  any  pain  and  fresh  dressings 
applied.  These  were  changed  in  two  days.  Some  serous  exudate  was  found.  The 
wound  remained  much  the  same  in  appearance.  About  the  tenth  day  suppuration 
became  more  apparent,  and  finally  extended  down  to  the  aponeurosis  of  the  external 
oblique,  a  portion  of  which  sloughed  away.  Healing  was  very  slow.  The  patient 
remained  in  the  ward  over  one  month  and  became  restless  and  left  before  healing  was 
complete.  I  do  not  know  what  effect  the  infection  will  have  upon  the  final  result.  I 
asked  the  patient  to  return  for  later  observation,  but  he  did  not  do  so. 

Epithelioma  of  right  cheek:  Mr.  C.,  aged  fifty-one,  carpenter".  Growth  was  as  large 
as  a  quarter  and  had  existed  for  three  years.  Operation  in  office,  January  5,  1910; 
Y±  of  i  per  cent,  quinin  and  urea  was  attemped,  but  proved  insufficient  after  fifteen 
minutes'  delay.  The  strength  was  gradually  increased  until  i  per  cent,  was  used,  which 
produced  profound  anesthesia.  The  growth  was  removed  by  a  wide  incision  and  good 
approximation  of  the  wound  secured  with  silk  sutures.  A  suitable  dressing  was  applied 
and  changed  in  two  days,  whe  much  induration  of  the  wound  was  noticed.  Infection 
became  apparent  by  the  fifth  day.  The  wound  was  three  weeks  in  healing  and  left 
quite  a  scar. 

Many  other  minor  operations  were  performed  before  and  since 
these  detailed  cases,  including  circumcisions,  hemorrhoids,  rectal 
fissures,  fistulas,  varicocele,  buboes,  etc.,  most  of  which  were  done  in 
the  office.  From  0.25  to  i  per  cent,  in  sterile  water  or  salt  solution 
was  used.  The  weaker  solutions  proved  effective  in  loose  cellular 
tissues,  like  the  scrotum  or  skin  of  the  penis,  and  their  use  was  always 
followed  by  less  induration  and  less  danger  of  slough  than  the  stronger 
solutions.  I  did  not  find  that  the  addition  of  normal  salt  solution 
influenced  the  results  to  any  marked  extent.  About  the  rectum  the 
i  per  cent,  solution  was  always  found  necessary,  and  succeeded  well 
in  all  but  one  case,  when  it  was  abandoned  and  cocain  used. 

The  after-effects,  when  used  about  the  rectum,  are  in  marked 
contrast  to  that  following  the  use  of  cocain  solution.  When  the 
quinin  solution  was  used  in  the  removal  of  hemorrhoids,  practically 
no  after-discomfort  was  complained  of,  the  anesthesia  lasting  until 
healing  was  well  under  way,  while  similar  operations  performed  with 
a  cocain  solution  are  always  followed  by  much  burning  and  pain  after 


LOCAL   ANESTHETICS  113 

the  anesthesia  dies  out.  Particularly  about  this  region  is  a  prelim- 
inary injection  of  a  syringe  full  of  Schleich  solution,  to  prevent  the 
burning  sensation  following  the  first  injection  of  the  quinin  solution, 
advisable.  As  some  infection  always  follows  operations  on  these 
parts,  I  have  not  found  that  the  quinin  solution  added  to  the  sup- 
puration sufficiently  to  be  objectionable,  but  judgment  must  be  used 
in  selecting  the  operation  for  its  use  or  embarrassing  results  may 
follow. 

I  would  not  care  to  undertake  a  resection  of  the  bowel  or  extensive 
Whitehead  operation  with  quinin  as  the  anesthetic,  but  if  a  local 
anesthetic  was  to  be  used  would  much  prefer  a  novocain  solution. 

In  circumcisions  the  0.25  per  cent,  solution  has  some  points  to 
commend  it.  The  pain  and  discomfort  associated  with  the  trying 
erections  which  follow  this  operation  are  absent  when  quinin  is  used 
and  no  discomfort  is  experienced  when  changing  the  dressings. 

In  seven  circumcisions,  performed  in  this  way,  I  have  had  fairly 
good  results,  and  much  time  and  annoyance  was  saved  myself  and 
the  patient,  and  I  have  not  found  that  healing  was  interfered  with 
to  any  great  extent.  The  wound  was  generally  well  in  about  ten 
days. 

However,  I  noticed  in  several  of  the  cases  that  the  infiltrated  skin 
often  had  a  dark  ecchymotic  appearance  afterward,  which,  at  times, 
took  on  a  threatening  aspect.  I  have  accordingly  discontinued  its 
Use  in  these  parts  for  fear  of  possible  serious  consequences. 

I  have  used  it  in  the  bladder  in  15  and  20  per  cent,  solutions,  but 
did  not  obtain  very  satisfactory  results.  Used  topically  in  the  rec- 
tum in  the  above  strengths  it  has  given  fair  results.  A  very  thorough 
study  of  its  action  and  surgical  uses  was  undertaken  by  Drs.  Hertzler, 
Brewster,  and  Rogers,  and  reported  in  the  "Journal  of  the  American 
Medical  Association,"  October  23,  1909.  I  quote  the  following  from 
their  report: 

"Hertzler  undertook  to  determine  experimentally  the  cause  of 
the  induration.  Experiments  performed  on  rabbits  showed  that  the 
thickening  was  not  due  to  cellular  infiltration  at  all,  as  was  supposed 
on  clinical  grounds,  but  was  due  to  a  pure  fibrinous  exudate  free  from 
cells.  This  exudate  was  proved  to  be  fibrin  by  Mallory's  and  Weig- 
ert's  stain.  The  reaction  appears,  therefore,  to  be  purely  chemical 
in  nature.  The  exudation  of  the  fibrin  begins  to  appear  within  a  few 
minutes.  In  a  general  way  it  determined  the  amount  of  exudate  de- 
pending on  the  strength  of  the  solution  used;  the  attempt  was  made, 
therefore,  to  determine  a  strength  of  solution  which  would  not  cause 


114  LOCAL  ANESTHESIA 

V 

this  exudation  of  fibrin.  In  0.5  per  cent,  solutions  the  exudate  is 
less  than  with  i  per  cent.,  and  with  only  0.25  per  cent,  solutions  only 
traces  can  be  discovered.  To  what  extent  this  fibrinous  exudate  is 
subsequently  converted  into  fibrous  tissue  has  not  yet  been  definitely 
determined,  but  apparently  nearly  all  is  absorbed. 

"In  order  to  determine  the  subjective  sensations  of  the  injection, 
and  to  determine  the  question  of  a  possible  zone  of  hyperesthesia 
about  the  anesthetized  zone,  one  of  us  (Hertzler)  studied  the  effect 
by  the  injections  in  the  skin  of  his  leg.  Injections  of  i,  0.5,  0.25, 
and  0.167  Per  cent,  solutions  and  an  injection  of  plain  water  as  con- 
trols were  used  in  each  series.  The  i  and  0.5  per  cent,  solutions  gave 
immediate  and  complete  anesthesia  without  a  particle  of  pain  during 
its  introduction.  Within  a  few  minutes  there  was  a  distinct  indura- 
tion. With  the  0.25  per  cent,  solution,  anesthesia  was  not  complete 
for  a  few  minutes,  but  was  then  as  complete  as  after  the  use  of  the 
stronger  solutions.  The  0.167  per  cent,  solution  gave  delayed  anes- 
thesia, but  after  a  few  minutes  was  complete.  In  neither  of  these 
weaker  solutions  was  induration  noted  on  palpation.  The  water- 
control  caused  intense  pain  on  injection,  and  the  anesthesia,  at  no 
time  perfect,  lasted  but  a  few  minutes.  There  was  a  zone  of  hyper- 
esthesia, i  or  2  inches  in  width,  about  the  area  injected.  Curiously 
enough  the  hyperesthesia  seemed  to  be  for  touch  and  not  for  pain. 

"The  duration  of  the  anesthesia  in  the  i  and  0.5  per  cent,  solu- 
tions was  perfect  for  four  or  five  days,  and  sensation  in  the  0.5  per 
cent,  strength  was  not  restored  to  any  great  extent  for  ten  days,  and 
in  the  i  per  cent,  solution  sensation  was  not  completely  restored 
after  two  weeks.  At  no  time  was  there  the  least  pain,  though  the 
induration  about  the  i  and  0.5  per  cent,  solutions  was  yet  marked 
at  one  and  two  weeks,  respectively. 

"The  above  observations  were  made  with  the  solution  of  the 
quinin  in  water.  When  physiologic  salt  solution  was  used  as  the 
solvent,  the  induration  was  little  or  not  at  all  marked,  but  the  dura- 
tion of  the  anesthesia  was  much  lessened.  Hypotonic  and  hyper- 
tonic  solutions  also  were  used  without  notable  variation. 

"The  result  of  this  experimentation  indicated  that  the  delayed 
skin  union  above  noted  was  due  to  fibrinous  exudate.  This  was  pres- 
ent in  the  i  and  0.5  per  cent,  solutions,  but  not  in  the  0.25  percent, 
solution  to  any  notable  degree.  The  0.25  per  cent,  solution  seemed, 
then,  on  laboratory  grounds,  to  be  the  strength  most  desirable  for 
anesthesia  in  the  class  of  work  where  speedy  primary  union  of  the 
skin  is  desirable,  and  where  duration  of  anesthesia  beyond  several 


LOCAL   ANESTHETICS  1 15 

hours  is  not  required,  and  clinical  experience  seems  to  bear  out  the 
laboratory  determinations. 

"Any  operations  ordinarily  done  with  cocain  can  be  done  with 
quinin.  The  technic  of  its  use  is  the  same.  As  in  the  use  of  cocain, 
only  those  tissues  known  to  be  sensitive  should  be  injected.  In  clean 
tissue  the  0.25  per  cent,  solution  seems  to  be  strong  enough  to  pro- 
duce anesthesia,  lasting  several  hours.  -In  regions  where  primary 
union  is  not  necessary,  particularly  in  tissue,  the  seat  of  inflammatory 
reaction,  the  stronger  solutions  are  more  satisfactory.  In  the  open- 
ing of  the  abscesses,  for  instance,  and  operations  for  anal  fistuals, 
hemorrhoids,  etc.,  the  stronger  solutions  are  the  ones  of  choice.  In 
regions  where  the  operation  is  attended  by  hemorrhage,  too,  notably 
tonsillectomy,  tubinectomy,  etc.,  the  i  per  cent,  solution  or  stronger 
(3  per  cent.,  Brown)  is  the  solution  of  choice.  The  strong  solution 
is  desired  here  because  of  the  hemostatic  effect  exercised  by  the 
fibrinous  exudate.  The  exudate  being  fibrin  in  the  strict  chemical 
sense,  the  usual  natural  processes  of  hemostasis  are  anticipated.  The 
coagulum  occurs,  it  is  true,  about  and  not  in  the  vessels,  and  their 
occlusion,  therefore,  results  from  the  pressure  from  without.  The 
important  point,  however,  is  that  the  effect  lasts  from  seven  to  four- 
teen days,  a  time  abundantly  sufficient  to  allow  healing  by  granula- 
tion to  become  well  advanced.  This  is  in  marked  contrast  to  the 
ephemeral  influence  of  cocain  and  adrenalin,  which  act  only  by 
causing  a  contraction  of  the  muscular  walls  of  the  blood-vessels. 

"We  have  done  the  following  operations,  among  others,  under 
quinin  anesthesia :  Drainage  of  the  gall-bladder,  drainage  of  appendi- 
ceal  abscesses,  exploratory  laparotomies,  hernias,  castrations,  varico- 
cele  and  hydrocele  operations,  etc.,  and  the  removal  of  all  sorts  of 
tumors  ordinarily  undertaken  under  cocain. 

"We  desire  particularly  to  emphasize  the  value  of  this  anesthetic 
in  two  operations.  In  operations  about  the  anus  it  is  for  us  the 
anesthetic  of  choice.  In  both  fistulas  and  hemorrhoids  any  of  the 
radical  operations  can  be  performed  with  the  same  thoroughness  as 
under  a  general  anesthetic.  The  advantage  consists  in  that  the 
duration  of  the  anesthetic  is  from  seven  to  ten  days,  which  does 
away  entirely  with  the  after-pain  ordinarily  attending  these  opera- 
tions. In  tonsillectomy  the  results  have  been  equally  satisfactory. 
For  this  operation  a  large  amount  of  the  solution  is  injected  about 
the  tonsil,  between  it  and  the  faucial  pillars.'  This  forms  an  artificial 
edema  about  the  tonsil  which  much  facilitates  its  removal.  An  un- 
limited amount  of  solution  may  be  used  with  impunity,  so  that  a 


Il6  LOCAL   ANESTHESIA 

satisfactory  anesthesia  can  be  easily  secured.  Because  of  its  safety, 
both  tonsils  may  be  operated  on  at  one  sitting.  The  absence  of  after- 
pain  is  as  desirable  here  as  following  an  operation  about  the  anus. 

"As  a  local  application  about  the  eye  we  have  no  experience,  but 
turbinectomies  and  septal  spur  operations  have  been  done  with  a 
fair  degree  of  satisfaction  when  the  drug  was  used  as  a  topical  appli- 
cation. For  local  application  the  strength  must  be  from  10  to  20 
per  cent.,  as  correctly  stated  by  Thibault.  When  the  solution  is  in- 
jected beneath  the  mucosa,  however,  anesthesia  is  perfect  and  hem- 
orrhage slight. 

"In  the  bladder,  as  a  preliminary  to  cystoscopy,  the  result  has 
been  very  satisfactory.  A  solution  of  from  10  to  20  per  cent,  is  used 
and  allowed  to  remain  from  twenty  to  thirty  minutes.  The  only 
objection  to  this  solution  is  the  difficulty  of  removing  the  precipitated 
flocculi  from  the  bladder  after  the  anesthesia  is  complete.  These 
flocculi  work  no  further  mischief  than  to  obscure  the  vision." 

Quinin  and  urea  hydrochlorid  has  been  recommended  in  the 
treatment  of  neuralgia.  We  have  had  but  a  limited  experience  with 
it  in  this  field,  and  that  has  not  been  satisfactory.  The  following  is 
from  a  recent  article  by  Dr.  Matas: 

"I  have  had  occasion  to  try  both  the  bichlorid  of  urea  and  quinin 
and  the  bisulphat  in  the  treatment  of  trigeminal  neuralgia,  and  as  a 
preliminary  to  the  extirpation  of  the  second  and  third  divisions  of 
the  trigeminus,  associated  with  the  alcohol  injections  into  these 
nerves  at  their  exit  from  the  base  of  the  skull  (Schlosser's  method). 
My  experience  has  brought  out  most  forcibly  the  objections  above 
stated: 

"In  the  case  of  an  aged  gentleman,  Judge  H.,  aged  seventy-three  years,  who  con- 
sulted me  two  months  ago  for  a  most  violent  tic  douloureux  of  the  infra-orbital  and 
inferior  maxillary  divisions  of  the  trigeminus,  I  felt  especially  anxious  to  avoid  any 
extensive  operation  which  might  require  a  general  anesthetic,  because  he  was  a  corpu- 
lent man  with  a  dilated  heart,  chronic  asthma,  and  emphysematous  lung.  I  decided  in 
this  case  to  try,  as  on  many  previous  occasions,  the  effect  of  a  deep,  massive  infiltration 
of  the  nerve-trunks  at  the  base  of  the  skull,  and  thus  obtain  a  regional  anesthesia,  as  a 
preliminary  to  the  excision  of  the  nerves  after  injection  of  the  nerve-trunks  with  alcohol. 
I  used  a  solution  of  quinin  bisulphate  (i  per  cent.)  with  adrenalin  solution  (i  :  1000), 
20  minims  of  the  adrenalin  to  5  ounces  of  quinin  solution.  With  my  special  infiltration 
apparatus  I  edematized  the  sphenomaxillary  and  zygomatic  fossae  by  introducing  the 
needle  of  the  pump  into  these  regions  through  the  sigmoid  notch  of  the  lower  jaw. 
The  anesthetic  effect  on  the  peripheral  distribution  of  the  nerves  was  pronounced  in  half 
an  hour,  but  in  a  few  hours  I  was  much  worried  by  the  persistence  of  the  edematous  swell- 
ing of  the  entire  cheek  and  face  on  the  corresponding  side  and  extreme  induration  of  the 
infiltrated  parts.  The  paroxysms  of  pain,  which  subsided  for  a  day,  gradually  returned 
to  their  original  violence,  the  hard  swelling  of  the  cheek  persisting  for  nearly  two  weeks. 


LOCAL   ANESTHETICS  1 17 

I  then  decided  to  reinject  the  nerves  with  my  regular  beta-eucain  (0.2  per  cent.)  and 
adrenalin  solution.  With  this  infiltration  the  anesthesia  was  so  complete  that  I  was 
able  to  resect  both  nerves  painlessly.  The  inferior  maxillary  was  exposed  above  the 
origin  of  the  inferior  dental  by  deepening  the  sigmoid  notch  and  following  the  nerves 
toward  the  foramen  ovale  (Victor  Horsley's  method).  The  infra-orbital  nerve  was 
exposed  and  followed  through  the  orbit  to  the  sphenopalatine  fossa  by  a  simplified  Car- 
nochan  method.  Both  nerve-trunks  were  injected  interstitially  with  alcohol  as  near  the 
point  of  exit  as  possible  from  the  skull,  and  then  torn  away  by  twisting  with  forceps,  the 
peripheral  distribution  being  extracted  by  Thiersch's  method.  The  relief  obtained  by 
this  procedure  was  complete  and  satisfactory. 

"In  this  case  I  learned,  first,  that  the  anesthetic  effect  of  the 
quinin  solution  was  not  as  pronounced  as  when  beta-eucain  was  used ; 
and,  second,  that  the  long-lasting  hard  swelling  after  the  quinin,  even 
when  used  in  combination  with  adrenalin,  was  not  a  negligible  after- 
effect." 

The  intra-abdominal  use  of  the  drug  was  tried  by  Dr.  Thibault, 
and  reported  in  the  "Journal  of  the  American  Medical  Association" 
in  the  article  which  I  quote  below.  In  view  of  the  non-toxicity  of  the 
drug,  and  the  consequent  freedom  with  which  it  can  be  used,  its 
action  here  should  be  borne  in  mind,  as  it  may  prove  of  advantage 
under  certain  conditions. 

The  following  report  of  an  experience  with  the  bimuriate  of  quinin 
and  urea  hydrochlorid  may  prove  of  some  value  to  surgeons  doing 
abdominal  work,  especially  in  cases  in  which  general  anesthesia  is 
undesirable: 

"  History. — Strangulation  of  an  old  inguinal  hernia  occurred  March  10,  in  a  negress 
aged  sixty-four,  who  had,  in  addition,  inoperable  cancer  of  the  uterus  and  rectum.  The 
circulation  was  poor.  There  were  arrythmia,  edema,  considerable  arterial  sclerosis, 
beginning  dilatation  of  the  heart;  slight  cough,  some  preliminary  secretion,  and  a  par- 
enchymatous  nephritis. 

"Operation. — Immediate  operation  was  necessary,  and  both  physicians  called  in  con- 
sultation thought  that  general  anesthesia  would  almost  certainly  prove  fatal.  The 
operation  was  done  under  local  anesthesia,  induced  by  injecting  0.25  per  cent,  solution  of 
quinin  and  urea  hydrochlorid.  The  tissues  above  the  canal  were  moderately  infiltrated 
with  the  solution  and  there  was  no  pain  until  after  the  canal  was  laid  open,  when  the 
peritoneum  was  found  to  be  quite  sensitive.  About  2  drams  of  the  warmed  solution  was 
poured  into  the  canal  and  in  a  few  minutes  there  was  perfect  anesthesia  of  the  parietal 
peritoneum  and  the  operation  was  finished  without  the  patient  at  any  subsequent  time 
feeling  any  pain,  although  considerable  adhesions  were  broken  up.  There  was  no  local 
reaction  in  the  peritoneum,  union  was  primary,  and  there  was  no  shock.  The  fluid 
poured  into  the  canal  gradually  escaped  into  the  abdomen  as  the  adhesions  were  broken 
up.  There  was  no  pain  after  the  operation  and  nothing  to  indicate  that  any  peritoneal 
irritation  had  taken  place. 

"While  it  is  dangerous  to  draw  conclusions  from  a  single  case, 
this  report  is  at  least  worth  attention,  and  suggests  that  the  solution 
might  be  poured  into  the  abdomen  and  more  extensive  operations 


Il8  LOCAL  ANESTHESIA 

done  without  pain  or  injury  to  the  patient,  as  the  presence  of  the 
solution  seems  to  render  the  handling  of  the  abdominal  viscera 
painless." 

Judging  quinin  by  the  standard  set  for  any  new  local  anesthetic, 
and  comparing  the  many  claims  made  for  it  with  our  clinical  expe- 
rience, we  find  that  (i)  compared  with  cocain,  novocain,  and  beta- 
eucain,  its  local  anesthetic  effect  is  not  as  rapidly  obtained.  This 
is  especially  true  of  its  topical  application  to  mucous  membranes. 
On  the  other  hand,  when  the  anesthesia  is  obtained,  it  is  of  very 
much  longer  duration,  the  after-pain  in  some  operations  being  thus 
avoided,  a  great  advantage  in  nasal  and  rectal  work  when  painful 
dressings  must  be  removed  shortly  after  the  operation.  (2)  The 
local  anesthetic  effect  is  not  only  slower  in  its  appearance,  five  to 
fifteen  minutes,  but  is  less  diffused.  It  spreads  over  a  more  restricted 
area  than  with  cocain  and  other  local  anesthetics.  (3)  Quinin  acts 
as  a  vasodilator  and  favors  capillary  oozing.  (4)  It  produces  a  sec- 
ondary indurative  reaction  in  the  tissues,  due  to  a  fibrinous  exudate, 
which  appears  a  few  minutes  after  injection-  and  in  a  general  way  is 
dependent  upon  the  concentration  of  the  solution. 

While  from  the  point  of  view  of  repair  this  excess  of  fibrinous  reac- 
tion is  a  disadvantage,  since  it  tends  to  interfere  with  the  healing  of 
wounds,  it  is  also  an  advantage  in  producing  a  secondary  and  per- 
manent hemostatic  effect  by  producing  a  perivascular  compression, 
which  may  be  utilised  profitably  in  some  operations  associated  with 
much  secondary  oozing.  This  may  be  the  case  in  rhinologic  work  and 
in  hemorrhoidal  operations,  where,  in  addition  to  long  anesthesia, 
a  permanent  hemostasis  is  desirable. 

The  primary  vasodilator  effect  and  interference  with  healing, 
with  long  persistence  of  hard  swelling  when  the  more  effective  quinin 
solutions  are  used,  is  a  serious  drawback  in  aseptic  operations  where 
quick  primary  healing  is  desirable,  and  will  militate  against  the  gen- 
eral acceptance  of  quinin  as  a  routine  anesthetic,  its  non-toxicity 
notwithstanding.  It  is  possible  that  by  combining  the  quinin  and 
urea  hydrochlorid  with  adrenalin  solution  the  objectionable  oozing 
due  to  the  primary  vasodilator  effect  may  be  overcome;  but  it  would 
appear  that  by  this  combination  the  vasoconstrictor  effect  of  the 
adrenalin  is  diminished  and  the  ischemia  is  not  obtained,  as  is  the 
case  when  some  of  the  cocain  substitutes  are  combined  with  adrenalin 
(Gaudier).  Neither  does  this  combination  appear  to  have  a  very 
marked  influence  in  diminishing  the  objectionable  fibrinous  exuda- 
tion of  quinin  in  my  experience. 


LOCAL   ANESTHETICS 

The  practice  of  combining  two  or  more  drugs  in  solutions  weaker 
than  any  one  could  have  been  effectively  used  alone  has  lately  met 
with  much  favor,  thereby  often  retaining  the  good  points  of  each 
while  being  able  to  eliminate  objectionable  effects.  Schleich,  in  this 
way,  has  combined  alypin  with  cocain  in  the  formulae  for  his  solutions 
which  he  recommends  at  present.  It  may  be  possible  to  combine 
quinin  in  this  way,  thereby  retaining  some  of  its  desirable  qualities. 

In  conclusion,  it  is  only  fair  to  state  that  whatever  may  be  the 
objections  to  the  routine  use  of  the  quinin  as  a  local  anesthetic  in 
surgical  practice,  we  must  admit  that  there  is  always  place  for  as 
reliable  an  anesthetic  as  quinin  has  proved  to  be.  (Brewer  has  in- 
jected 100  gr.  of  the  bichlorid  of  urea  and  quinin  intravenously  in 
the  course  of  six  hours  in  a  case  of  pernicious  malarial  infection  with- 
out ill  effects.) 

This  non-toxicity,  coupled  with  the  extraordinary  duration  of  the 
anesthesia  (one  to  six  days),  will  always  keep  this  remarkable  drug 
in  the  mind  of  every  surgeon  who  is  constantly  facing  the  problem 
of  -local  anesthesia  in  its  multitudinous  phases  in  the  daily  routine  of 
surgical  practice.  Furthermore,  in  view  of  the  remarkable  proper- 
ties which  quinin  possesses,  as  above  stated,  it  is  to  be  hoped  that 
every  effort  will  be  made  to  overcome  the  objections  which  we  have 
previously  noticed  by  combining  its  salts  with  other  agents  that  will 
modify  or  neutralize  its  undesirable  reaction  in  the  tissues. 

In  discovering  this  unknown  and  most  valuable  property  in  a 
long-familiar  drug,  Dr.  Thibault  has  contributed  a  valuable  addition 
to  the  surgeon's  resources  in  annulling  pain  and  has  proved  himself 
an  unusually  keen  and  perspicuous  observer. 

While  the  study  of  the  local  action  of  this  drug  is  highly  interesting, 
we  do  not  feel,  in  the  present  stage  of  its  development,  that  we  can 
recommend  its  use  for  any  but  a  limited  number  of  rectal  operations; 
possibly  the  surgeon  specialist  may  select  it  for  certain  nose  and 
throat  work. 

An  interesting  point  upon  which  we  have  been  unable  to  secure 
any  information  is  its  surgical  use  as  an  anesthetic  on  those  said  to 
possess  an  idiosyncrasy  to  the  drug.  In  the  large  number  of  cases 
already  reported  no  such  observations  have  been  made. 

Investigations  conducted  by  the  author  with  other  salts  of  quinin 
to  determine  if  some  salt  could  not  be  found  retaining  the  desirable 
qualities  of  quinin  analgesia  while  lacking  its  irritant  or  necrotic 
action  has  been  disappointing,  these  properties  are  essentially  the 
action  of  the  quinin  regardless  of  its  form.  Some  salts  are  more 


120  LOCAL  ANESTHESIA 

irritant  than  others  but  all  possess  this  quality;  quinin  and  urea 
apparently  are  the  least  objectionable.  Several  local  anesthetics 
were  tried  in  various  combinations  but  particularly  nocovain.  This 
drug  when  combined  with  quinin  and  urea  hydrochlorid  makes 
an  unstable  mixture  if  kept  for  any  length  of  time  and  if  used  this 
way  should  be  mixed  just  before  using.  Quinin  and  urea  hydro- 
chlorid like  most  other  xanthin  salts  is  unstable  in  any  mixture. 
From  a  chemical  standpoint  such  salts  as  the  bimuriate  are  quite 
stable,  but  not  so  soluble;  this  salt  and  the  chlorid  combine  well 
with  novocain,  but  are  more  irritant  than  the  urea  combination. 
Limited  experiments  conducted  by  myself  have  not  proved  satis- 
factory but  the  subject  is  deserving  of  further  investigation. 

While  this  book  is  going  through  the  press  there  appears  in  the 
literature  an  article  by  Dr.  F.  W.  Parham,  on  Quinin  and  Tetanus 
("New  Orleans  Med.  and  Surg.  Jour.,"  October,  1913),  in  which  this 
valuable  drug  is  incriminated  as  an  exciting  cause  of  tetanus.  This 
arraignment  is  so  convincing  that  I  record  it  here  as  a  caution  against 
its  unguarded  use,  particularly  as  there  appears  the  tendency  to  ex- 
tend the  field  of  usefulness  of  quinin  as  an  anesthetic.  At  least  one 
fatal  case  of  this  dread  disease  has  occurred  recently  in  New  Orleans 
in  which  quinin  seemed  to  have  been  the  exciting  cause. 

In  all  cases  so  far  in  which  tetanus  has  followed  the  quinin  was 
in  concentrated  solution,  and  usually  administered  for  malaria.  The 
determining  factor  seems  to  have  been  the  area  of  necrosis  which  the 
injection  produced,  this  would  seem  possible  in  the  solutions  ordi- 
narily used  for  purposes  of  anesthesia,  0.25  to  i  per  cent.,  which  at 
times  has  been  found  to  produce  necrosis.  As  this  mere  statement 
of  facts  may  fail  of  its  purpose  without  the  production  of  further 
proof  or  argument,  I  copy  the  following  taken  from  Dr.  Parham's 
article,  which  is  a  quotation  from  Major  S.  P.  James,  January,  1911, 
number  of  Paludism,  in  which  he  summarizes  the  work  of  Sir  David 
Semple  on  this  subject: 

"  Cases  of  tetanus  sometimes  occur  after  the  hypodermic  or  intra- 
muscular administration  of  quinin,  and  it  may  now  be  regarded  as 
proved  that  such  cases  are  not  always  due  to  a  contaminated  needle 
or  solution,  but  sometimes  occur  in  circumstances  in  which  the  ster- 
ility of  the  apparatus  used,  of  the  fluid  injected,  and  of  the  patient's 
skin  at  the  site  of  injection  is  assured.  The  results  of  the  present 
investigation  indicate  the  probable  cause  of  such  cases,  the  danger 
attending  the  hypodermic  or  intramuscular  administration  of  quinin, 
and  the  procedure  by  which  that  danger  may  be  avoided. 


LOCAL   ANESTHETICS  121 

"The  author's  explanation  of  the  occurrence  of  tetanus  when  no 
tetanus  spores  have  been  injected  with  the  quinin  solution  rests  upon 
the  following  findings:  (i)  Many  people  in  good  health  harbor 
tetanus  spores  in  their  bodies,  either  in  healed  wounds  or  in  the  in- 
testinal canal.  Hidden  away  in  the  tissues  the  spores  remain  alive 
and  retain  their  virulence,  but,  for  one  reason  or  another,  they  do  not 
grow  into  toxin-producing  bacilli.  It  appears  that  such  tetanus- 
spore  carriers  may  be  quite  common,  for,  as  regards  the  intestinal 
canal  carrier,  Colonel  Semple  found  the  spores  in  the  feces  of  four 
out  of  every  ten  persons  examined.  The  frequency  of  '  healed-wound 
carriers '  is  not  known,  but  probably  is  considerable,  for  it  is  reason- 
able to  suppose  that  the  majority  of  people  have  suffered  slight  in- 
juries accompanied  by  the  introduction  of  tetanus  spores,  but  not 
followed  by  tetanus,  and  that  at  least  some  of  these  people  harbor 
in  the  healed  tissues  a  few  spores  which  have  not  been  destroyed  by 
the  phagocytes,  and  which,  from  the  absence  of  anerobic  conditions, 
or  from  some  other  cause,  do  not  grow  into  toxin-producing  bacilli. 
In  the  thirteenth  series  of  experiments  described  by  Colonel  Semple, 
eight  guinea-pigs  were  inoculated  in  the  hind  leg  with  spores  entirely 
free  from  toxin  ('washed  tetanus  spores').  The  animals  remained 
healthy.  At  periods  varying  from  five  weeks  to  seven  months  after 
inoculation  the  guinea-pigs  were  killed,  and  small  pieces  of  the  sub- 
cutaneous tissue  at  the  site  of  inoculation  were  removed  aseptically, 
placed  in  tubes  of  broth,  and  incubated.  In  all  the  eight  experi- 
ments true  tetanus  bacilli,  which  were  found  to  be  virulent,  were 
recovered.  These  results  prove  that  living  tetanus  spores  can  remain 
in  the  tissues  for  at  least  seven  months  without  being  destroyed  by 
the  phagocytes  and  without  causing  tetanus;  and  it  is  reasonable  to 
suppose  that  a  similar  condition  obtains  in  persons  who  have  suffered 
an  injury  accompanied  by  the  introduction  of  tetanus  spores,  but 
hot  followed  by  tetanus;  most  of  the  spores  are  followed  by  phagocy- 
tosis, but  some  of  them  escape  and  become  hidden  away  in  the  tissues, 
where  they  remain  for  months  or  years  after  the  wound  has  healed. 
(2)  The  second  finding  is  that  these  tetanus-spore  carriers  are  in 
danger  of  suffering  from  tetanus:  (a)  on  the  occurrence  of  circum- 
stances (such  as  great  fatigue  or  exposure  to  extremes  of  heat  and 
cold)  which  lower  their  normal  power  of  keeping  at  bay  the  germs 
which  they  harbor;  (b)  when  the  site  where  the  spores  are  lodged 
becomes  converted  into  a  medium  which,  from  being  anerobic  and 
from  a  failure  of  phagocytosis,  is  favorable  for  the  growth  of  the  spores 
into  toxin-producing  bacilli;  (c)  when  a  focus  of  dead  tissues  forms  in 


122  LOCAL   ANESTHESIA 

a  part  of  the  body  at  a  distance  from  the  site  where  the  spores  are 
lodged. 

"For  our  present  purposes  the  third  of  these  conditions  is  the 
most  important,  and  in  regard  to  it  Colonel  Semple  has  proved,  espe- 
cially by  his  series  of  experiments  numbered  III,  VII,  XVI,  and 
XVII,  that  the  'latent'  or  'dormant'  tetanus  spores  are  sometimes 
conveyed  from  the  site  where  they  were  harmless  to  a  site  (such  as 
that  of  a  quinin  injection)  where  they  can  develop  abundantly  and 
produce  sufficient  toxin  to  cause  tetanus.  (3)  The  third  finding  is 
that  the  results  of  injecting  quinin  hypodermically  or  intramuscu- 
larly are,  (a)  local  destruction  of  tissue,  and  in  most  cases  the  forma- 
tion of  a  slough  which  includes  the  true  skin,  the  subcutaneous  tissue, 
and  the  deep  fasciae;  this  means  the  formation  of  a  subcutaneous 
necrotic  area  which  is  an  anerobic  medium  very  favorable  to  the 
growth  of  tetanus  spores;  (&)  the  paralysis  of  the  leukocytes  so  that 
their  phagocytic  action  is  hindered. 

"If  we  have  interpreted  Colonel  Semple's  paper  rightly,  the  ex- 
planation of  the  occurrence  of  tetanus  after  an  uncontaminated  and 
aseptic  hypodermic  or  intramuscular  injection  of  quinin,  is,  on  the 
basis  of  the  above  findings,  not  difficult.  Suppose  the  malaria  pa- 
tient to  be  a  tetanus-spore  carrier,  the  spores  being  situated  in  the 
intestinal  canal,  and  suppose  we  inject  the  quinin  solution  into  the 
patient's  buttock,  and  by  so  doing  produce  there  a  local  subcutaneous 
patch  of  dead  tissue,  leukocytes  from  all  parts  will  crowd  to  the  in- 
jected area,  and  it  may  happen  that  some  of  them  contain  tetanus 
spores  gathered  from  the  alimentary  canal  as  a  result  of  an  abrasion 
of  the  mucous  membrane.  The  spores  that  have  been  conveyed  to 
the  necrotic  patch  will  find  the  conditions  there  very  suitable  for 
development  into  toxin-producing  bacilli,  and  tetanus  will  ensue. 
Similar  events  might  happen  if  the  tetanus-spore  carrier  was  a  person 
in  whom  the  'latent'  or  'dormant'  spores  were  situated  in  the  site 
of  an  old  wound  on  any  part  of  the  body. 

"If  we  accept  this  explanation,  it  is  easy  to  understand  why,  even 
in  tetanus-spore  carriers,  injections  of  non-irritating  drugs,  such  as 
morphin,  cocain  or  digitalin,  are  not  followed  by  tetanus.  These 
solutions  are  quickly  absorbed  and  no  local  destruction  of  tissue  re- 
sults, so  that  the  person  remains  free  from  a  focus  suitable  for  the 
germination  and  growth  of  the  spores;  and  as  regards  those  drugs, 
even  if  tetanus  spores  were  injected  along  with  the  solution,  it  is 
probable  that,  the  activity  of  the  leukocytes  being  unimpaired,  all 
the  spores  would  be  destroyed  at  the  site  of  the  injection. 


LOCAL   ANESTHETICS  123 

"From  this  brief  sketch  it  will  be  clear  that  there  is  considerable 
danger  in  administering  quinin  hypodermically  or  intramuscularly, 
even  with  the  strictest  aseptic  care.  For  this  reason  it  is  fortunate 
that  Colonel  Semple  has  been  able  to  prove,  by  his  nineteenth  series 
of  experiments,  that  tetanus  antitoxin  is  a  trustworthy  prophylactic 
against  tetanus  when  it  is  necessary  to  administer  quinin  by  those 
methods.  When  the  drug  has  to  be  administered  hypodermically  or 
intramuscularly,  an  injection  of  antitetanic  serum  should  be  given 
immediately  before,  or  immediately  after,  the  quinin  injection. 
Colonel  Semple  recommends  an  injection  of  10  to  15  c.c.  of  the  serum 
into  the  loose  subcutaneous  tissues  of  the  side  of  the  abdomen,  and 
states  that  this  amount  would  confer  upon  the  patient  a  passive  im- 
munity to  tetanus  for  two  or  three  weeks.  If  this  procedure  is 
adopted,  the  hypodermic  and  intramuscular  administration  of  quinin 
can,  so  far  as  the  danger  of  tetanus  is  concerned,  be  carried  out  with 
safety." 

ANESTHETIC  PROPERTIES  OF  MAGNESIUM  SALTS 

The  anesthetic  properties  of  magnesium  salts  were  discovered 
through  the  experiments  of  Dr.  S.  J.  Meltzer,  of  New  York.  He  had 
reasoned  that  the  phenomena  of  life  results  from  the  interaction  of 
excitation  and  inhibition.  There  are  four  principal  inorganic  con- 
stituents of  the  body — sodium,  potassium,  calcium,  and  magnesium. 
Of  these,  the  first  three  have  been  shown  to  possess  a  stimulatory 
effect  on  muscle  and  nerve.  It,  therefore,  remained  for  magnesium 
to  exert  an  antagonistic  or  inhibitory  effect.  The  theory  was  ac- 
cordingly put  to  test.  The  application  of  magnesium  sulphate  to 
nerve-trunks  was  found  to  block  conductivity  and  abolish  excita- 
bility. The  intracerebral  injection  of  magnesium  sulphate  was  next 
tried,  and  found  to  induce  a  state  of  general  inhibition;  subcutane- 
ously,  it  produced  deep  narcosis  and  complete  muscular  relaxation; 
intravenously,  it  produced  the  same  effect,  also  arresting  intestinal 
peristalsis.  Both  the  subcutaneous  and  intravenous  injections  pro- 
duced complete  muscular  relaxation  in  tetanus,  lasting  often  as  long 
as  twenty-four  hours.  These  experiments  were  tested  by  many  and 
found  to  be  correct,  but  when  locally  applied  to  an  open  wound  it 
did  not  seem  to  exert  any  sedative  action. 

Guthrie  and  Ryan,  in  testing  the  action  of  magnesium  salts,  came 
to  the  conclusion  that  they  produce  a  general  muscular  paralysis, 
and  in  this  state  the  animals  were  unable  to  respond  to  sensory  stimu- 
lation, and  when  general  anesthesia  was  produced  it  was  due  to  the 


124  LOCAL  ANESTHESIA 

paralysis  extending  to  the  respiratory  muscle,  and  the  degree  of  an- 
esthesia depended  upon  the  degree  of  asphyxiation. 

This  contention  was  later  disproved  by  Meltzer,  and  confirmed 
by  the  intraspinal  injection  of  magnesium  sulphate  on  human  sub- 
jects. These  were  operated  upon  in  a  thoroughly  conscious  state 
with  undisturbed  respiration,  but  completely  anesthetic  below  the 
point  of  injection.  It  leaves  no  doubt  regarding  the  anesthetic  prop- 
erties of  magnesium  sulphate. 

(For  the  intraspinal  injection,  see  section  on  this  subject.) 

The  intracerebral  injection  of  magnesium  chlorid  has  been  tried 
on  laboratory  animals  and  found  to  produce  complete  muscular  and 
sensory  paralysis,  and  has  been  suggested  as  a  means  of  anesthesia 
for  laboratory  use. 

Notwithstanding  the  undoubted  paralyzing  effects  of  magnesium 
salts  in  tetanus,  where  it  has  been  tried  and  found  to  control  the 
convulsions,  its  depressing  effect  was  too  great  and  no  reduction  was 
accomplished  in  the  mortality,  the  high  temperature  continuing  and 
the  patient  dying  from  exhaustion  or  as  a  result  of  the  action  of  the 
toxins  of  the  disease. 

Local  applications  of  solutions  of  magnesium  sulphate  have  been 
found  to  give  relief  when  used  for  neuralgias,  headache,  pleurisy, 
pericarditis,  and  various  abdominal  pains.  This  sedative  action  is 
by  no  means  constant  and  often  fails,  but  it  is  a  simple  method  and 
worthy  of  trial  where  opiates  and  other  sedatives  are  to  be  avoided. 
This  sedation  is  not  accompanied  by  any  local  anesthesia,  but  seems 
to  be  through  reflex  action. 

Some  additional  experimental  data  has  been  contributed  by  De 
Neen,  Amer.  Jour,  of  Surgery,  January,  1916,  in  which  he  concludes: 

"  i.  Magnesium  is  toxic  in  large  doses. 

"2.  That  it  will  cause  respiratory  paralysis. 

"3.  That  it  will  cause  general  anesthesia  although  the  animal  is 
conscious. 

"4.  That  it  will  cause  sloughing,  and  gangrene  in  some  cases, 
when  introduced  subcutaneously  or  intramuscularly.  Or  when  it 
escapes  into  the  muscles  or  connective  tissue. 

"5.  That  it  is  not  a  local  anesthetic. 

"6.  That  the  toxic  and  therapeutic  dose  vary  in  different  dogs. 

"7.  That  the  time  required  to  inject  is  about  thirty  minutes. 

"8.  That  when  the  dose  is  given  in  too  short  a  time,  respiratory 
paralysis  or  death  may  result. 

"9.  That  the  intravenous  route  is  the  best." 


CHAPTER  VI 
TOXICOLOGY 

SINCE  the  introduction  of  Schleich's  infiltration  anesthesia,  we 
have  the  knowledge  that  effective  operative  analgesia  of  the  tissues 
may  be  obtained  with  solutions  as  weak  as  i :  20,000.  This  knowl- 
edge has  caused  an  abandonment  of  the  use  of  the  strong  solutions 
(5,  10  or  even  20  per  cent.)  that  were  in  common  use  in  the  early 
days  of  cocain  anesthesia.  From  these  strong  solutions  resulted  a 
tremendous  array  of  fatalities,  that  brought  discredit  to  the  use  of 
cocain.  The  improvement  in  present  methods  by  the  addition  of 
adrenalin  and  other  aids,  and  the  uses  of  weak  solutions  (0.25  or 
0.20  per  cent,  for  ordinary  infiltration;  or  0.5  to  i  per  cent,  for  nerve- 
blocking)  has  greatly  lessened  the  toxic  action  of  cocain  in  general 
surgery.  Men  of  large  experience  have  not  had  a  single  case  of  toxic 
action  resulting  from  the  use  of  this  drug. 

In  our  own  experience  we  have  fortunately  not  had  a  case  of 
poisoning  from  cocain  or  its  allied  drugs  to  deal  with,  but  have  occa- 
sionally seen  these  cases;  they  will  continue  to  occur  in  the  hands  of 
those  inexperienced  in  its  use  and  its  dangers,  who  incautiously  use 
strong  solutions.  In  the  practice  of  dentists  and  surgical  specialists 
(eye,  ear,  nose,  and  throat),  who  make  use  of  solutions  stronger  than 
those  now  used  by  the  general  surgeon,  cases  of  poisoning  are  fre- 
quently occurring. 

The  solutions  used  in  this  line  of  work  are  often  i  per  cent,  for 
infiltration,  and  for  topical  application  10,  20,  and  30  per  cent.,  or 
even  stronger,  and  should  be  used  with  great  caution.  As  preven- 
tion is  better  than  cure,  apply  only  small  quantities  at  a  time,  and 
do  not  over-saturate  tampons  or  allow  the  solution  to  drop  to  other 
parts,  or  to  run  from  the  point  of  the  application  to  be  absorbed  else- 
where, and  always  safeguard  these  applications  with  adrenalin. 

The  poisonous  effects  of  cocain  and  its  allied  drugs  and  other 
agents  used  for  their  local  anesthetic  action  may  be  either  local  or 
constitutional.  As  illustrations  of  local  irritating  action  may  be 
mentioned  the  inflammation  occasionally  seen  to  follow  the  use  of 
alypin  and  stovain  in  strong  solutions,  and  the  action  of  stovain  on 
nerve- tissue,  notably  in  spinal  puncture;  also  the  local  necrotic  ac- 

125 


126  LOCAL  ANESTHESIA 

tion  of  quinin  and  urea,  or  the  local  destructive  and  inflammatory 
action  of  carbolic  acid.  The  prolonged  freezing  by  ethyl  chlorid  will 
produce  coagulation  with  destruction  of  tissue.  All  these  local  ef- 
fects are  discussed  in  the  chapters  with  the  action  of  these  different 
agents;  here  we  propose  to  discuss  the  general  or  constitutional  action. 

In  speaking  of  this  toxic  action  cocain  will  be  taken  as  the  type, 
for  what  applies  to  cocain  is  equally  applicable  to  all  of  its  congeners, 
with  perhaps  very  slight  or  inconsequential  differences  in  some  few 
cases. 

Cocain  is  recognized  as  a  universal  protoplasmic  poison  effecting 
all  protoplasm,  animal  and  vegetable  alike.  When  gradually  ab- 
sorbed in  toxic  doses,  acting  first  as  an  excitant,  paralysis  follows  after 
a  more  or  less  brief  period  of  excitement.  When  injected  into  the 
circulation  in  toxic  doses  the  stage  of  excitement  is  so  short  as  to 
escape  observation,  paralysis  taking  place  almost  immediately. 

It  must  be  remembered  that  the  local  anesthetic  action  of  cocain 
is  the  result  of  a  local  paralysis  of  the  parts  affected;  all  tissues  are 
similarly  effected  by  its  use,  nerves  of  special  sense,  motor  nerves, 
muscle-fiber  as  well  as  sensory  nerves,  and  white  blood-corpuscles 
loose  their  ameboid  movements  when  in  contact  with  its  solutions; 
its  constitutional  or  central  action  is  the  result  of  this  paralysis  upon 
the  higher  nerve-centers. 

This  paralysis  is  the  result  of  a  definite  chemical  combination, 
and  the  longer  the  solution  remains  in  contact  with  the  tissues  at 
the  point  of  injection  the  more  pronounced  becomes  this  chemical 
combination,  and  consequently  the  more  pronounced  the  anesthesia1 
(paralysis). 

These  facts  should  guide  us  in  its  use:  first,  to  keep  within  the 
limits  of  safety;  secondly,  to  use  means  to  retain  it  at  the  point  of 
injection  or  application;  and,  finally,  should  toxic  symptoms  arise, 
to  apply  at  once  such  measures  (constriction)  if  possible  as  will  check 
or  delay  further  absorption,  as  well  as  such  other  measures  as  have 
been  suggested  elsewhere  to  combat  this  toxic  action. 

The  soluble  salts  of  cocain  are  absorbed  with  great  rapidity. 
They  have  the  power  of  passing  with  great  facility  through  nearly 
all  mucous  membranes,  so  that  their  absorption  is  almost  immediate 
when  topically  employed  on  such  surfaces  as  the  nose,  throat,  mouth, 
urethra,  eye,  and  rectum,  consequently  the  greater  number  of  cases 
of  poisoning  have  resulted  from  their  use  in  this  way. 

The  ultimate  fate  of  cocain  after  absorption  into  the  body  is 
somewhat  in  doubt;  it  is  believed,  when  slowly  absorbed,  to  be  en- 


TOXICOLOGY  127 

tirely  broken  up  by  the  body-cells  (Moreno  y  Maiz);  when  more 
rapidly  absorbed  very  small  quantities  (5  per  cent.)  have  been  re- 
covered from  the  urine. 

It  is  believed  that  cocain  once  fixed  by  the  body-cells  (in  combina- 
tion with  them)  is  not  liberated  from  these  combinations  as  cocain, 
but  as  constituent  products,  ecgonin,  etc. ;  Glasenap  believes  he  has 
isolated  ecgonin  from  the  urine.  These  derivatives  of  cocain  are 
slightly  anesthetic  and  slightly  toxic,  but  much  less  so  than  cocain. 
As  a  result  of  the  preceding  statements  it  can  be  said  that  cocain 
exerts  its  full  anesthetic  or  toxic  action  but  once,  and  if  exhausted 
locally  there  will  be  no  constitutional  reaction. 

It  can  be  further  stated  that  that  portion  of  the  cocain  which  is 
absorbed  and  acts  upon  the  general  system  producing  toxic  symp- 
toms, is  the  excess  over  that  fixed  by  the  tissues  locally,  consequently 
that  much  in  excess  of  the  amount  needed  to  thoroughly  saturate 
and  combine  with  the  tissue-cells  producing  in  them  complete  paraly- 
sis. In  considering  this  statement  it  must  be  borne  in  mind  that  on 
very  actively  absorbing  srufaces  and  in  very  vascular  tissues,  where 
no  aids  are  used  to  retard  absorption,  such  as  constriction  or  adrena- 
lin, that  much  of  the  drug  is  rapidly  taken  up  and  transported  by 
the  veins  and  lymphatics  to  the  central  nervous  system  before  a  very 
limited  quantity  of  it  has  had  time  to  be  fixed  by  the  tissues  and  act 
locally.  This  and  other  statements  are  borne  out  by  clinical  experi- 
ences in  the  cases  of  poisoning  by  small  doses  in  comparison  to  the 
amount  used  under  other  conditions  without  ill  effects.  Mattison 
reports  a  case  by  Knabe  where  12  drops  of  a  4  per  cent,  solution 
given  hypodermically  to  a  young  girl  of  eleven  years  caused  death  in 
less  than  one  minute.  Garland  reports  a  death  following  the  appli- 
cation of  20  drops  of  a  5  per  cent,  solution  to  the  gums.  Hundreds 
of  such  cases  have  been  reported,  and  many  cases  of  idiosyncrasy 
showing  poisonous  symptoms  from  remarkably  small  doses;  these, 
however,  have  all  been  in  strong  solutions,  i  per  cent,  and  over,  and 
only  serve  to  emphasize  the  caution  given  that  when  using  such 
agents,  keep  well  within  the  safe  limits  and  use  only  the  weakest 
dilutions  compatible  with  efficiency;  the  toxic  action  will  vary  in 
direct  ratio  to  the  strength  of  the  solution  and  the  rapidity  of 
absorption. 

Three-quarters  of  a  grain  of  cocain  is  given  as  a  safe  average  dose, 
but  this  varies  within  wide  limits;  less  than  this  amount  may  produce 
poisonous  symptoms  if  too  rapidly  thrown  into  the  circulation  in 
susceptible  individuals,  while  many  times  this  amount  can  be  given 


128  LOCAL    ANESTHESIA 

when  well  diluted,  distributed  over  a  large  area,  and  safeguarded  by 
measures  to  retard  absorption. 

Patients  who  once  have  been  poisoned  by  cocain  often  show  a 
marked  susceptibility  to  remarkably  small  doses;  this  fact  should  be 
borne  in  mind  when  dealing  with  patients  who  give  such  a  history. 

The  power  of  the  tissue-cells  to  combine  with  and  destroy  cocain 
is  not  limited  to  this  agent  alone,  but  is  true  of  many  other  poisons, 
animal  as  well  as  vegetable;  we  may  mention  strychnin  and  snake 
venom,  particularly  in  the  case  of  snake-bite  upon  an  extremity;  all 
are  familiar  with  the  action  of  a  constrictor  proximal  to  the  point  of 
bite,  thus  retaining  in  situ  the  snake  venom,  allowing  it  to  exhaust 
its  force  upon  the  tissues  locally  which  intensifies  its  local  action, 
often  leading  to  extensive  necrosis  but  saving  the  general  system. 

The  same  is  true  of  cocain,  many  times  the  toxic  dose  can  be  in- 
jected into  the  tissues  locally  if  retained  in  situ  by  the  use  of  a  con- 
strictor or  adrenalin.  Particularly  with  a  constrictor,  and  largely 
diluted  so  as  to  be  freely  diffused  and  brought  into  contact  with  a 
larger  number  of  tissue-cells,  when  if  retained  sufficiently  long  the 
strength  of  the  drug  is  exhausted  and  little  or  no  constitutional  effect 
will  be  noted,  if  liberated  into  the  general  system.  In  the  case  of 
excessive  doses  this  should  be  gradually  done  by  the  intermittent 
relaxation  of  the  constrictor. 

The  relative  toxic  effects  of  the  drug  when  liberated  into  the  sys- 
tem by  various  routes  has  frequently  been  the  subject  of  study. 

Petrow  found  in  animal  experimentation  that  the  toxic  dose  was 
two  to  three  times  greater  when  using  a  constrictor,  which,  however, 
was  not  allowed  to  remain  on  very  long  (time  not  given),  while  the 
lethal  dose  was  seven  to  ten  times  greater  than  that  needed  without 
a  constrictor. 

V.  Oppel,  in  experimenting  along  the  same  lines,  found  that  the 
lethal  dose  of  cocain  when  injected  into  the  arteries  is  eight  to  ten 
times  greater  than  the  intravenous,  while  subcutaneous  injections 
are  two  to  three  times  less  dangerous  than  the  arterial  and  fifteen 
to  twenty  times  less  dangerous  than  intravenous  injections.  Other 
observers,  in  working  along  the  same  lines,  have  arrived  at  nearly 
similar  conclusions. 

In  considering  the  above  statement,  it  is  readily  understood  how 
the  intra-arterial  injections  are  more  dangerous  than  subcutaneous 
ones.  It  is  realized  that,  even  though  the  solution  is  being  carried 
away  from  the  centers,  it  does  not  leave  the  lumen  of  the  vessels,  and 
the  time  required  for  the  circuit  is  comparatively  short  when  meas- 


TOXICOLOGY  I2Q 

ured  by  the  time  necessary  for  cocain  solutions  to  combine  with  the 
tissues,  besides  the  entire  volume  is  delivered  at  once  into  the  gen- 
eral circulation  with  the  returning  blood.  The  subcutaneous  injec- 
tions are  weakened  by  the  action  of  the  tissue-cells  outside  of  the 
vessels,  and  are  gradually  taken  up  to  be  slowly  liberated  into  the 
general  circulation. 

The  age  and  condition  of  the  patient  is  also  an  active  factor  in 
considering  the  toxicology  of  these  drugs;  childhood  and  early  youth, 
due  to  the  highly  sensitive  and  impressionable  nervous  system,  as 
well  as  the  influence  which  psychic  impressions  may  play,  are  rela- 
tively much  more  susceptible  to  the  toxic  influence  of  these  drugs 
than  are  adults;  on  the  other  hand,  old  age,  where  so  often  general 
anesthetics  may  be  contra-indicated,  is  particularly  favorable  to  all 
local  anesthetic  procedures.  This  question  of  age  is  considered  more 
thoroughly  under  Indications  and  Centra-indications,  as  well  as 
other  conditions  of  the  patient  which  may  operate  for  or  against  the 
toxic  action  of  these  drugs.  While  %  gr.  of  cocain  is  given  as  the 
maximum  safe  dose  that  can  be  absorbed  into  the  circulation  at  any 
one  time,  still  this  dose  may  be  many  times  exceeded  with  perfect 
safety  when  largely  diluted,  diffused  over  a  large  area,  and  slowly 
absorbed;  the  danger  of  toxicity  depends  entirely  upon  the  strength 
of  the  solution  and  rapidity  of  absorption;  we  have  repeatedly  used, 
8,  10,  or  12  ounces  of  Schleich's  solution  No.  i,  containing  0.96  gr. 
of  cocain  to  the  ounce,  or  our  solution  No.  i,  containing  1.2  gr.  of 
novocain  to  the  ounce,  when  performing  very  large  and  extensive 
operations  under  infiltration  anesthesia,  without  ever  having  seen 
any  toxic  effects;  32  ounces  of  solution  No.  i,  containing  38.4  gr.  of 
novocain,  was  used  in  doing  an  extensive  lipectomy  without  any  dis- 
turbance. Of  course,  in  these  procedures  some  of  the  solution  es- 
capes from  the  tissues  through  the  incisions,  and  the  total  quantity 
absorbed  is  in  this  way  somewhat  reduced.  The  precaution  men- 
tioned elsewhere,  of  keeping  the  patient  recumbent  with  head  low  for 
several  hours  after  operation  where  large  doses  of  the  drug  have  been 
used,  may  again  be  emphasized  here;  also  when  operating  upon  an 
extremity  under  similar  conditions  to  intermittently  relax  the  con- 
strictor rather  than  removing  it  entirely  upon  the  completion  of  the 
operation. 

Cocain  produces  a  veritable  general  analgesia  as  a  final  stage  in 
all  severe  intoxications,  but  only  when  the  life  of  the  animal  is  seri- 
ously threatened;  this  is  not  only  of  interest  to  the  physiologist, 
but  to  the  surgeon  as  well.  (See  General  Anesthesia  with  Cocain.) 


130  LOCAL  ANESTHESIA 

The  local  action  of  cocain,  aside  from  its  anesthetic  action,  is  that 
of  a  vasoconstrictor,  producing  a  decided  degree  of  anemia;  it  is  be- 
lieved that  its  central  toxic  action  is  ushered  in  by  similar  phenom- 
ena— anemia  of  the  cerebrum  and  vital  nerve-centers,  producing  at 
first  a  brief  period  of  excitement  or  irritation,  followed  by  paralysis; 
these  symptoms  may  be  of  mild  degree  and  slow  to  develop,  passing 
off  without  serious  results,  or  appear  suddenly  and  end  in  a  fatal 
termination  within  a  few  moments,  depending  upon  the  size  of  the . 
dose  and  the  rapidity  of  absorption. 

Many  operators  have  tried  to  prevent  or  lessen  this  central  toxic 
action  by  adding  to  the  cocain  solution  various  drugs  to  combat  this 
central  vasoconstriction,  or  by  using  a  combination  of  anesthetic 
drugs ;  have  hoped  to  be  able  to  reduce  the  quantity  of  cocain  needed 
to  a  point  well  below  the  toxic  dose,  even  when  large  quantities  of  the 
solution  was  necessary.  Thus,  Stuver  advised  a  mixture  consisting  of 
one  part  of  cocain  to  two  parts  of  antipyrin;  Gluck  advised  carbolic 
acid  and  Parker  resorcin.  To  combat  the  vasoconstriction,  Thomas 
and  Guitton  have  recommended  the  addition  of  nitroglycerin.  All 
these  combinations  are  objectionable  from  many  points,  some  of 
them  being  irritant  and  others  fully  as  toxic  or  depressing.  What 
is  wanted  is  to  simplify  rather  than  complicate  the  mixtures.  The 
use  of  vasodilators  having  a  local  action  is  especially  to  be  avoided, 
for  many  reasons  the  local  anemia  is  desired  and  we  try  to  intensify 
it  by  the  use  of  such  aids  as  adrenalin  or  by  the  use  of  cold;  this 
local  anemia,  besides  increasing  its  local  action,  lessens  or  prevents 
its  central  or  constitutional  action  by  prolonging  the  sojourn  of  the 
drug  in  the  tissues^  where  its  action  is  weakened  or  entirely  exhausted. 

It  is  also  quite  doubtful  that  such  drugs  are  of  any  value  in  com- 
bating the  toxic  effects;  what  is  better  is  to  keep  well  within  the  limits 
of  safety,  and,  should  toxic  symptoms  occur,  to  meet  them  by  other 
more  effective  means. 

The  symptoms  of  mild  intoxication  may  be  evident  in  loquacity, 
laughing,  or  singing,  later  slight  nausea,  vertigo,  faintness,  thoracic 
oppression;  as  the  severity  of  the  symptoms  increase,  the  pulse  which 
at  first  is  stimulated  becomes  rapid  and  weak,  respiration  may  be 
oppressed  or  quite  rapid,  great  mental  excitement  and  anxiety  may 
occur,  the  patient  becoming  very  restless  with  twitching  or  trembling 
of  the  muscles,  these  symptoms  indicating  the  threatening  onset  of 
convulsions;  at  times  the  stage  of  excitement  may  manifest  itself  by 
maniacal  delirium,  the  patient  becoming  violent  and  uncontrollable; 
convulsions  with  unconsciousness  may  now  supervene  and  be  fol- 


TOXICOLOGY  131 

lowed  by  death.  During  the  onset  of  symptoms  the  pupils  are  usu- 
ally dilated,  but  may  at  times  be  contracted.  The  order  and  char- 
acter of  symptoms  may  vary  greatly  in  different  individuals,  the 
stage  of  excitement  may  be  absent,  unconsciousness  coming  on  at 
once,  followed  by  convulsions.  In  some  cases  where  the  toxic  dose 
is  very  large,  or  the  patient  is  particularly  susceptible,  death  may 
occur  almost  immediately  from  cardiac  inhibition. 

The  onset  of  mild  symptoms,  such  as  loquacity  or  faintness,  are 
usually  controlled  by  having  the  patient  maintain  the  horizontal 
position  or  by  lowering  the  head  of  the  table;  this  position  should  be 
continued  for  half  an  hour  or  longer  following  the  disappearance  of 
all  symptoms.  The  use  of  drugs  to  combat  poisonous  symptoms 
must  be  largely  symptomatic.  If  syncopy  occurs,  or  the  heart  be- 
comes weakened,  strychnin  and  digitalis  should  be  used,  preferably 
given  by  hypodermic,  while  ammonia  or  amyl  nitrite  are  given  by 
inhalation.  For  nervous  excitement  or  convulsions  H.  C.  Wood 
recommends  chloroform  by  inhalations,  but  it  would  appear  that 
ether  should  be  better,  particularly  if  it  be  proved  that  the  central 
action  is  associated  with  the  same  vasoconstriction  and  anemia  that 
takes  place  in  its  local  field  of  action ;  inhalations  of  ether,  due  to  the 
tremendous  congestion  which  it  produces  in  these  parts,  should  prove 
of  great  value,  besides  stimulating  vasomotors,  heart  and  respiration 
and  controlling  the  convulsions;  nitrous  oxid  would  be  equally  as 
valuable;  amyl  nitrite,  while  producing  the  same  congesting  effect, 
would  not  exert  the  same  controlling  influence  upon  the  convulsions. 

Regarding  the  use  of  ether  a  very  interesting  report  has  lately 
been  published  in  the  "Journal  American  Medical  Association"  by 
Dr.  J.  E.  Engstadt,  which  we  quote  in  part  as  follows: 

"In  the  first  few  cases  I  was  called  on  to  treat,  strychnin  and 
morphin  in  combination  were  used  with  a  marked  benefit.  But,  as 
cases  kept  multiplying,  I  found  the  action  of  these  drugs  too  slow,  and 
I  decided  that  there  must  be  something  to  counteract  the  poison 
more  rapidly  when  life  was  in  extreme  danger.  It  was  necessary  to 
find  a  remedy  that  could  be  administered  at  any  time  and  be  in- 
stantaneous in  its  action.  I  soon  found  ether  to  be  the  required  drug. 
This  was  administered  as  ordinarily  given  to  produce  surgical  narco- 
sis. Ether  stimulates  the  vasomotor  system,  is  a  tonic  to  the  heart 
muscles,  stimulates  the  action  of  the  respiratory  centers  of  the  brain 
and  of  the  pneumogastric  nerve,  and  increases  the  pulmonary  circu- 
lation in  the  first  stages.  While  cocain  inhibits  the  action  of  the 
heart,  especially  on  the  right  side,  it  has  also  a  marked  inhibitory 


132  LOCAL  ANESTHESIA 

action  on  the  respiratory  centers  of  the  brain.  Death  may  occur 
from  feeble  respiratory  movements  of  the  so-called  Cheyne-Stokes 
type  or  asphyxia. 

"To  me  ether  has  proved  extremely  valuable.  It  has  saved  what 
seemed  hopeless  cases.  It  stimulates  the  heart  and  the  respiratory 
system  almost  instantly.  The  pulse  becomes  fuller  at  once  and  of 
normal  tension.  The  marked  mental  excitement  is  allayed  as  the 
patient  goes  under  the  influence  of  the  ether  and  the  effect  of  the 
poison  rapidly  disappears.  The  individual  regains  consciousness  as 
soon  as  the  effect  of  the  small  amount  of  ether  has  disappeared." 

To  get  the  best  results,  the  anesthetic  is  administered  only  to  the 
degree  of  mild  surgical  narcosis,  or,  at  times,  even  less  than  this. 
A  mask  should  be  employed  and  the  ether  given  by  the  drop  method. 
This  is  all-important.  Given  by  the  old  method,  the  ether  would 
only  add  to  the  danger  of  asphyxia  by  excluding  air  from  the  venous- 
blood  engorged  lungs. 

It  is  quite  interesting  to  compare  the  sedative  and  controlling 
influence  of  ether  upon  the  symptoms  of  cocain  intoxication,  as  re- 
ported by  Engstadt,  with  the  sedative  effects  of  a  hypodermic  of 
cocain  upon  animals  coming  out  of  ether  narcosis  (although  not 
operated  upon),  as  reported  by  Kast  and  Meltzer  in  the  chapter  on 
Abdominal  Operations. 

It  was  thought  for  some  time  that  adrenalin  lessens  the  toxic 
action  of  cocain  upon  the  central  nervous  system,  but  upon  later 
investigation  this  has  been  found  to  be  in  error,  and  that  after  the 
cocain  once  enters  the  general  circulation  the  use  of  adrenalin  may 
increase  its  toxic  action ;  this  may  be  understood  when  it  is  considered 
that  both  produce  vasoconstriction.  Adrenalin  greatly  lessens  the 
likelihood  of  development  of  toxic  symptoms  by  retaining  the  cocain 
in  the  field  of  injection,  and  greatly  intensifying  and  prolonging  its 
action  there,  where  it  is  largely  exhausted  by  action  upon  the  tissues, 
but  after  it  has  once  entered  the  general  circulation  the  adrenalin 
may  prove  a  distinct  disadvantage. 

The  observations  of  J.  M.  Berry  on  this  subject  are  particularly 
interesting.  He  concludes  his  remarks  as  follows:  "In  the  use  of 
adrenalin-cocain  care  should  be  exercised  not  to  inject  a  toxic  dose 
of  the  latter,  for  not  only  does  the  adrenalin  fail  to  protect  the  body 
against  the  toxic  doses  of  cocain,  but  it  seems  to  enhance  the  toxic 
action." 

Thriss  found,  by  experiments  on  cats,  that  cocain  and  adrenalin, 
when  injected  into  the  lumbar  sac,  had  the  same  toxic  effect  as  when 


TOXICOLOGY  133 

cocain  was  used  alone.  Miles  and  Muhlberg,  in  a  series  of  experi- 
ments upon  animals  for  the  study  of  the  comparative  value  of  adrena- 
lin and  other  substances  upon  vasomotor  depression  artificially 
produced,  conclude  that  "adrenalin  subcutaneously  is  indicated  on 
theoretic  ground  for  the  vasomotor  collapse  following  cocain  or 
chloroform  poisoning,  etc."  Here,  however,  it  is  to  be  used  to  com- 
bat a  symptom,  and  not  in  any  sense  as  an  antidote. 

Braun,  in  his  book  on  local  anesthesia,  and  elsewhere  in  the 
"Archiv.  f.  klin.  Chir.,"  vol.  Ixix,  does  not  concur  in  these  views,  but 
believes  that  adrenalin  lessens  the  central  toxic  action;  on  the  other 
hand,  Petrow  found  that  adrenalin  did  not  seem  to  exert  any  great 
influence  upon  the  toxic  action. 

In  considering  the  toxic  action  of  local  anesthetics  it  should  be 
borne  in  mind  that  the  too  free  use  of  adrenalin  may  excite  symptoms 
in  susceptible  individuals  notably  in  nervous  conditions  and  high 
blood-pressure,  these  symptoms  are  usually  a  feeling  of  oppression 
in  the  chest,  a  fulness  and  throbbing  in  the  head  with  headache,  the 
face  is  usually  flushed  and  the  pulse  tense;  quite  a  different  picture 
from  cocain  poisoning.  (See  chapter  on  Adrenalin.) 

The  toxic  symptoms  of  cocain  poisoning  are  due  to  its  paralyzing, 
action  on  the  respiratory,  cardiac  and  vasomotor  centers  as  well  as 
some  influence  being  exerted  by  its  direct  action  upon  the  cardiac  and 
vasomotor  muscles  due  to  its  universal  action  on  all  protoplasm. 
Opium,  its  alkaloids  and  all  narcotic  drugs  antagonize  this  action  by 
dulling  the  sensibility  and  response  of  these  centers  and  are  therefore 
true  antagonists.  This  action  is,  however,  best  exerted  as  a  prophy- 
lactic, or  preventative  by  their  preliminary  use  before  the  injection 
of  the  anesthetic  when  it  does  certainly  permit  the  use  of  much  larger 
doses  of  the  anesthetic  and  in  this  way  acts  as  a  direct  antagonist. 
Mild  toxic  symptoms  are  favorably  influenced  by  morphin  or  panto- 
pon  administered  hypodermically  after  their  onset  but  with  severe 
symptoms,  except  for  a  slight  lessening  of  the  convulsions  its  bene- 
ficial influence  is  not  so  marked. 

Strychnin  by  its  stimulating  effect  upon  all  nerve-tissue  should 
certainly  antagonize  the  paralytic  influence  of  cocain  and  by  its  in- 
fluence help  to  keep  the  flagging  respiratory  centers  at  work  and  sup- 
port the  blood-pressure  until  the  crisis  has  been  passed,  while  these 
and  other  means  may  be  of  benefit,  ether  by  light  inhalation  unques- 
tionably meets  all  the  indications  and  except  in  absolutely  lethal 
doses  is  usually  able  to  control  the  symptoms. 

The  use  of  intravenous  salt  injections,  as  recommended  for  all 


134  LOCAL   ANESTHESIA 

poisons,  may  be  tried  for  cocain  when  time  permits.  The  diluting 
effects  of  a  pint  or  quart  of  normal  salt  solution  should  have  a  favor- 
able influence  in  weakening  the  toxic  strength  of  the  drug,  as  well  as 
stimulating  the  heart  and  favoring  more  rapid  elimination. 

Carlo  Bozzo  found  that  the  minimum  fatal  dose  of  cocain  for  dogs, 
injected  hypodermically,  was  0.025  gram  per  kilo,  without  infusion,, 
but  when  infusion  was  resorted  to  the  minimum  fatal  dose  rose  to 
0.03  per  kilo;  he  concludes  that  besides  favoring  rapid  elimination 
it  retards  the  absorption  of  further  quantities  of  the  drug,  owing  to 
the  fulness  of  the  blood-vessels. 

The  development  of  toxic  symptoms  from  the  use  of  cocain  may 
be  considerably  delayed,  or,  after  apparent  recovery,  the  patient  may 
again  sink  into  a  state  of  syncopy  or  collapse.  As  an  illustration 
of  this  condition,  the  author  was  called  to  see  a  case  of  convulsions  in 
a  young  man  twenty-four  years  old,  and  obtained  the  following  his- 
tory: Two  hours  previously  he  had  two  molar  teeth  extracted  by  the 
use  of  local  injections  of  cocain;  it  was  necessary  for  the  dentist  to 
make  repeated  injections  before  securing  the  necessary  anesthesia; 
the  extractions  were  finally  painless;  following  the  procedure  there 
was  slight  nausea  and  some  vertigo,  for.  which  he  was  given  a  drink  of 
whisky,  when  he  appeared  to  recover,  and  was  able  to  go  home  in  the 
street  cars  a  distance  of  about  twenty  city  blocks;  after  arriving  at 
home  he  felt  uneasy  and  restless  and  sat  in  a  chair  in  his  gallery;  he 
was  found  sometime  later  by  his  family,  still  in  the  chair,  but  in  a 
state  of  convulsion;  when  the  writer  arrived  he  had  had  several  such 
seizures,  at  intervals  of  about  fifteen  or  twenty  minutes,  becoming 
quite  uncontrollable  and  violent  just  before  their  onset;  as  I  had 
learned  the  nature  of  the  case  I  went  prepared.  The  patient  was 
frantic  upon  my  arrival,  requiring  the  combined  efforts  of  several  of 
the  family  to  hold  him ;  his  pupils  were  widely  dilated,  face  very  pale, 
studded  with  large  drops  of  perspiration,  and  his  expression  one  of 
terror;  the  respirations  were  rapid  and  shallow,  the  pulse  small,  feeble, 
and  rapid.  We  at  once  threw  the  patient  across  the  bed,  where  he  was 
held  while  I  administered  ether  by  the  drop  method  to  the  point  of 
superficial  anesthesia ;  with  the  beginning  of  the  ether  administration 
there  was  an  immediate  change,  the  respirations  deepened,  the  pulse 
slowed  and  became  fuller,  the  color  returning  to  the  face,  the  muscles 
which  had  been  tense  soon  relaxed ;  the  entire  picture  was  changed,  the 
patient  presenting  the  usual  appearance  of  one  under  light  ether 
narcosis;  this  was  kept  up  for  about  fifteen  or  twenty  minutes  and 
gradually  suspended.  The  feet  and  hips  were  then  elevated  upon 


TOXICOLOGY  135 

pillows  until  the  head  was  quite  dependent;  this  position  was  main- 
tained while  the  patient  came  from  under  the  influence  of  the  ether 
and  for  sometime  afterward.  I  remained  with  him  for  about  one- 
half  hour  after  he  appeared  normal  to  make  sure  that  there  would  be 
no  return  of  the  symptoms,  but  beyond  a  feeling  of  exhaustion  there 
was  no  further  disturbance.  Next  day  he  appeared  quite  normal; 
later  examination  of  his  kidneys  and  other  organs  failed  to  show  any- 
thing abnormal. 

Parsons  reports  that  following  collapse  in  spinal  anesthesia  light 
ether  inhalations  have  proved  of  immediate  and  marked  benefit. 

J.  K.  Pedley  reports  a  case  related  by  Dr.  B.  Christensen,  in  which  a  young  woman 
aged  twenty-eight  had  the  root  of  a  tooth  extracted  under  novocain  anesthesia  and  died 
several  hours  later:  "At  1.45  P.  M.  I  injected  about  i%  c.c.  of  a  little  less  than  a  2  per 
cent,  solution  of  novocain-suprarenin  (Tab.  B.  Containing  novocain,  o.i  gram,  supra- 
renin,  0.00045  gram),  but  as  the  anesthesia  was  insufficient  ten  minutes  later  I  injected 
some  more,  in  all  about  3  c.c.  The  patient  felt  rather  unwell  afterward  and  was  advised 
to  remain  in  the  office  and  lie  down. 

"  From  4  to  4.30  she  was  sitting  up  and  chatting;  at  5.30  she  had  so  much  improved 
the  doctor  left  her;  at  6.30  his  wife  noticed  her  and  she  seemed  to  be  in  a  natural  sleep; 
shortly  later  noticed  her  breathing  rather  deeply  and  on  examination  found  her  almost 
pulseless;  gave  camphor  by  needle. 

"At  7  P.  M.  doctor  returned  and  performed  artificial  respiration,  at  8  p.  M.  was 
removed  to  the  hospital,  and  died  one  hour  later,  without  regaining  consciousness,  with 
symptoms  of  edema  of  lungs." 

Cases  of  this  kind  would  be  reported  in  great  number,  but  the 
above  will  suffice  for  an  illustration. 

To  recapitulate:  With  the  onset  of  the  first  symptoms  immedi- 
ately place  the  patient  in  a  recumbent  position  and  lower  the  head;  if 
the  operation  has  been  upon  an  extremity  apply  a  constrictor  proxi- 
mal to  the  field;  give  ammonia  or  amyl  nitrite  by  inhalation;  if  the 
case  seems  severe,  lightly  narcotize  with  ether  by  the  drop  method; 
use  digitalis  or  oil  of  camphor  by  needle  if  the  heart  is  weak;  in  severe 
cases  use  infusions  of  normal  salt  solutions  if  convenient;  should  the 
respiration  cease  artificial  respiration  should  be  resorted  to  and  per- 
sisted in  as  long  as  the  pulse  or  heart  is  perceptible  or  even  longer,  as 
there  may  be  a  chance  of  resuscitation.  Legrand  reports  a  case  where 
it  was  necessary  to  continue  artificial  respiration  for  five  hours  before 
the  function  became  normal.  In  such  cases,  where  the  facilities  are 
at  hand,  use  the  Meltzer-Auer  intratracheal  intubation  with  forced 
respiration. 

Some  of  the  earlier  cases  of  poisoning  may  have  resulted  from  the 
presence  of  certain  impurities  in  the  preparation  used,  and  this  may 
even  occur  now,  though  not  so  likely,  as  the  methods  of  manufacture 


136  LOCAL   ANESTHESIA 

and  safeguards  placed  around  it  have  so  far  improved  as  to  reduce 
this  likelihood  to  a  minimum. 

Some  of  these  impurities  have  never  been  determined,  but  a  few 
have  been  isolated  and  positively  identified ;  two  of  these,  which  in  the 
past  have  been  most  likely  to  occur,  are  isatropylcocain  and  cinnamyl- 
cocain,  both  highly  toxic;  as  these  impurities  act  in  different  ways, 
some  of  the  peculiar  toxic  symptoms  reported  may  be  accounted  for 
in  this  way. 


CHAPTER  VII 
ADRENALIN 

ADRENALIN,  the  therapeutic  constrictor,  is  known  under  several 
names  as  suprarenin,  paranephrin,  epirenin,  eudrenal,  and  epinephrin, 
but  probably  is  better  known  in  this  country  as  adrenalin,  the  name 
proposed  for  it  by  Takamine.  Adrenalin  and  the  synthetic  prepara- 
tions of  arterenol,  homorenon,  and  suprarenin  synthetic  are  powerful 
local  and  constitutional  vasoconstrictors,  and,  except  the  latter,  are 
obtained  as  an  extract  from  the  suprarenal  glands  of  animals. 

The  introduction  within  the  last  ten  years  of  this  highly  valuable 
and  wonderful  agent  has  proved  a  great  boon  to  many  departments 
of  surgery,  and  has  given  a  decided  impetus  to  all  local  anesthetic 
procedures.  Next  to  the  possession  of  safe  local  anesthetics  and  the 
Schleich  infiltration  method  (with  dilute  solutions),  there  is  no  single 
agent  or  factor  which  has  so  fostered  and  encouraged  the  development 
of  local  anesthesia,  and  enabled  surgeons  to  enlarge  the  field  and 
broaden  the  scope  of  all  purely  local  procedures. 

This  has  been  made  possible  by  the  unique  power  this  agent 
exercises  of  producing  vasoconstriction,  and  retaining  within  the  tis- 
sues the  dilute  anesthetics  which  both  intensifies  and  prolongs  their 
action  for  a  period  of  time  usually  well  beyond  that  required  for  the 
performance  of  any  ordinary  operation;  and  this  without  injury  to 
the  tissues. 

To  Prof.  Heinrich  Braun,  of  Zwickau,  Germany,  from  whom  we 
have  quoted  quite  liberally  in  this  volume,  is  largely  due  the  credit  of 
first  introducing,  developing,  and  perfecting  the  use  of  this  agent  in 
local  anesthesia.  Already  a  staunch  advocate  of  local  anesthesia,  in 
which  field  he  has  been  a  constant  worker,  he  was  quick  to  see  the 
advantages  of  a  combination  with  adrenalin  and  early  advocated  its 
use,  and  it  is  largely  due  to  his  efforts  in  this  direction  that  adrenalin 
soon  became  so  popular  an  adjunct  in  all  local  anesthetic  solutions. 

Adrenalin  has  become  almost  indispensable  to  the  surgical  special- 
ists, particularly  in  the  nose  and  throat,  where  it  is  in  constant  daily 
use,  both  for  purposes  of  examination  as  well  as  for  operations;  in 
examinations  it  greatly  facilitates  the  procedure  when  swabbed  or 
sprayed  on  turgid  and  congested  mucous  passages,  causing  them 
to  shrink  and  permit  free  access  and  inspection  of  the  deeper  parts. 
Nearly  all  operations  upon  these  parts  are  greatly  facilitated  and 

13? 


138  LOCAL  ANESTHESIA 

simplified  by  its  use,  which  renders  the  field  almost  entirely  bloodless, 
greatly  expediting  the  work;  and  enabling  the  operator  to  undertake 
many  operations  in  the  office  without  assistance  under  local  anesthe- 
sia and  without  the  loss  of  blood.  These  operations  formerly  were 
done  only  in  institutions  under  general  anesthesia,  with  considerable 
loss  of  blood  and  a  much  more  complicated  and  tedious  technic. 

The  history  of  the  early  work  which  led  to  the  discovery  of  adren- 
alin is  not  without  interest,  but  only  brief  mention  will  be  made  of  it 
here  in  expressing  our  gradtitude  to  those  who  have  given  us  this 
valuable  agent.  Early  anatomists  observed  that  the  juice  of  the 
medullary  susbstance  of  the  suprarenals  darkened  upon  exposure  to 
light  and  air;  they  called  this  substance  atra  bibis.  It  was  not,  how- 
ever, until  the  nineteenth  century  that  the  color  change  was  under- 
stood. Vulpian  in  1856  noticed  that  this  juice,  when  brought  into 
contact  with  ferric  chlorid  and  iodin,  turned  emerald  green  and  then 
rose  carmin.  These  reactions  were  characteristic  of  this  organ,  and 
led  to  the  opinion  that  the  gland  contained  a  physiologic  substance. 

Pellacani,  as  early  as  1879,  performed  a  very  interesting  series  of 
experiments  in  Foa's  laboratory  by  injecting  an  extract  of  the  fresh 
glands  into  various  animals.  Mattel  later  repeated  Pellacani's 
experiments,  and  came  to  the  conclusion  that  his  results  were  those  of 
septicemia  rather  than  from  any  special  active  principle  of  the  gland. 

In  1883  Foa  and  Pellacani  again  took  up  the  study  and  published 
some  interesting  results,  and  it  would  seem,  after  reading  the  original 
papers  of  these  early  writers,  that  more  credit  should  be  given  them, 
for  they  certainly  describe  symptoms  of  poisoning  which  are  now 
recognized  as  characteristic  of  adrenalin. 

Other  investigators  followed  up  this  line  of  work:  Krukenberg 
(1885),  Marino-Zuco  (1888),  Guarnieri  and  Marino-Zuco  (1888). 

The  synthetic  preparation  of  this  agent  began  to  be  fore- 
shadowed as  early  as  1893  by  the  work  of  Dr.  Zierzgowski,  who 
should  be  given  credit  for  pioneer  work  in  this  line. 

Gluzinski  (1895),  Moore  (1895),  Dubois  (1896),  and  Vincent 
(1897)  were  other  workers  with  these  glands.  In  1896  Frankel  sug- 
gested sphygmogenin  as  a  name  for  the  active  principle  of  the  gland; 
this  was,  however,  later  shown  to  be  a  mixture. 

The  work  that  had  been  done  by  the  earlier  investigators  prepared 
the  way  for  that  which  was  to  follow;  the  subsequent  investigations 
began  to  yield  better  results  in  isolating  the  active  principle  of  these 
glands.  Dreyer  had  also  been  able  to  isolate  the  active  principle  of 
the  suprarenals  in  the  veins  coming  from  these  glands. 


ADRENALIN  139 

Batelle  (1902)  claimed  to  have  obtained  a  purer  adrenalin  than 
that  produced  by  Takamine's  method. 

In  the  meantime  enough  data  had  accumulated  to  attempt  the 
synthetic  preparation,  although,  as  has  been  mentioned,  Dzierzgow- 
ski  in  1893  had  done  creditable  work  in  this  line.  Stolz  succeeded  in 
producing  the  so-called  dl-product,  which  was  found  to  be  somewhat 
different  from  the  natural  base.  This  was  found  by  Flacher  to  be  due 
to  dextro  and  levo  components  which  he  was  able  to  separate,  and 
found  that  the  levo-adrenalin  was  identical  with  that  obtained  from 
the  glands.  The  action  of  this  principle  began  now  to  be  extensively 
studied,  and  Cybulskilgo  pointed  out  that  concentrated  doses  were 
much  more  poisonous  than  when  diluted;  and  Gluzinski  determined 
that  intravenous  doses  were  more  toxic  than  subcutaneous.  The 
physiologic  investigators  began  now  to  become  more  numerous,  and 
the  literature  of  this  subject  is  filled  with  the  names  of  prominent 
investigators. 

In  1895  Oliver  and  Schafer,  and  Szymonowicz  and  Cybulski 
working  independently,  discovered  the  action  of  certain  suprarenal 
bodies  upon  the  circulation. 

Abel  in  1897,  working  along  the  same  lines,  was  able  to  isolate  a 
body  which  he  called  epinephrin. 

In  1900  Von  Furth  described  suprarenin,  and  in  1901  Takamine 
and  Aldrich  isolated  a  principle  which  Takamine  called  adrenalin. 
It  is  probable  that  these  two  last  substances  are  identical,  while 
epinephrin  seems  to  be  different  both  chemically  and  physiologically. 
Abel  regards  adrenalin  as  an  epinephrin  hydrate. 

Investigations  regarding  the  relative  merits  of  the  synthetic 
preparations  (dl-adrenalin,  known  commercially  as  arterenol,  and  the 
ethyl-amino-aceto-catechol,  known  as  homorenon)  conclude  that  the 
former  is  about  two-thirds  as  active  as  the  natural  product  and  the 
latter  about  one-eightieth  as  strong. 

The  structural  formula,  which  for  a  time  was  somewhat  in  dispute, 
now  seems  definitely  settled  by  both  analysis  and  synthesis  and  is  a 
most  precise  definition  of  a  pure  chemical  compound  and  is  defined  as 
the  levo-rotatory  isomer  of  the  formula 
HO  -C 


HO  -  C      CH 


HC      C  -  CH(OH)  -  CH2  -  NH(CH3) 

v 

C 
H 


140  LOCAL  ANESTHESIA 

The  dextro-rotatory  isomer  of  this  formula  which  is  only  found  in 
the  synthetic  product,  is  practically  inert.  From  a  careful  analysis 
of  this  formula,  it  is  seen  that  the  molecule  contains  groups  that 
characterize  it  as  an  amine  base,  an  alcohol  and  a  phenol,  observations 
which  explain  its  chemical  behavior. 

Adrenalin  is  found  naturally  in  the  medulla  of  the  suprarenal 
glands  of  all  vertebrates.  The  adrenalin  of  commerce  is  obtained 
from  beef  cattle,  but  there  is  no  reason  to  doubt  that  the  active  sub- 
stance is  the  same  from  whatever  animal  obtained.  The  adrenalin  of 
commerce  is  substantially  pure  containing  but  a  small  portion  of 
foreign  matter  and  is  a  nearly  white  microcrystalline  powder. 

When  stored  under  proper  precautions,  it  should  keep  for  many 
years — perhaps  permanently.  Air,  heat,  light,  moisture,  ammonia 
and  certain  other  gases,  affect  it  injuriously.  Under  the  combined 
influence  of  air,  heat  and  moisture,  it  decomposes  rapidly.  It 
should,  consequently,  be  preserved  in  absolutely  dry  colored  bottles; 
sealed  air  tight,  and  if  to  be  kept  for  an  indefinite  time,  the  air  should 
be  thoroughly  displaced  by  some  inert  gas. 

The  pure  adrenalin  base  is  slightly  soluble  in  cold  water,  slightly 
more  so  in  warm  water.  Certain  salts  increase  this  solubility:  thus 
solutions  of  borates  render  soluble  a  large  quantity  of  the  adrenalin 
and  prevent  the  precipitation  of  solutions  of  its  salts  by  alkalies.  A 
strong  aqueous  solution  of  chemically  neutral  adrenalin  chloride  will 
dissolve  an  appreciable  quantity  of  the  adrenalin  base. 

Due  to  its  phenol  characteristics,  it  forms  water  soluble  compounds 
with  fixed  caustic  alkalies,  but  not  with  their  carbonates  or  with 
ammonia.  From  strong  solutions  of  most  of  its  salts,  the  adrenalin 
base  is  partly  precipitated  by  hydroxides  or  carbonates  of  strong 
alkalies,  including  ammonia  and  redissolved  by  an  excess  of  the  fixed 
caustic  alkali  only. 

Due  to  its  amine  function,  adrenalin  forms  definite  salts  with 
acids,  usually  very  hydroscopic  and  difficult  to  preserve  in  dry  form. 
Most  of  these  salts  are  quite  soluble  in  water  and  alcohol  and  can  be 
made  quite  stable  for  ordinary  uses;  but  are  not  very  soluble  in  sol- 
vents other  than  water  and  alcohol.  For  most  purposes  we  are, 
therefore,  limited  to  the  use  of  its  salts  in  aqueous  or  alcoholic 
solution. 

In  the  preparation  of  ointments,  it  is  best  to  first  prepare  a  con- 
centrated aqueous  solution  in  dilute  hydrochloric  acid:  this  is  incor- 
porated with  sufficient  lanolin  which  takes  up  large  quantities  of 
water,  after  which  any  other  ointment  base  may  be  added.  In  case 


ADRENALIN  141 

the  fatty  base  is  soluble  in  alcohol,  it  may  at  times  be  desirable  to  first 
dissolve  the  adrenalin  in  sufficient  alcohol,  when  the  ointment  may 
then  be  added. 

Commercially  obtained,  adrenalin  chlorid  contains  i  part  per 
1000  of  adrenalin  chlorid  in  physiologic  salt  solution,  containing 
0.5  per  cent,  of  chloretone  to  preserve  it  and  is  saturated  with  carbon 
dioxid  used  in  its  manufacture  to  expel  the  air.  It  has  a  faintly  acid 
reaction,  smells  and  tastes  of  chloretone  and  sodium  chlorid.  When 
fresh,  it  should  be  colorless. 

When  properly  prepared  and  bottled,  it  should  remain  colorless 
and  retain  its  activity  for  a  long  period.  When  exposed  to  the  air 
and  light,  color  changes  and  deterioration  begins.  It  is  therefore 
best  kept  in  small  colored  bottles.  When  opened  for  use,  it  should  be 
immediately  stoppered  and  put  back  in  a  dark  place :  only  the  quan- 
tity to  be  immediately  used  should  be  removed. 

The  color  change  is  a  fair  index  of  its  deterioration.  It  first  be- 
comes pink,  then  red,  finally  brown  and  a  brown  precipitate  settles 
out.  Experiments  have  been  undertaken  to  determine  the  degree  of 
deterioration  based  on  these  color  changes,  which  might  be  used  as  a 
guide  in  its  use. 

The  following  is  approximately  reliable:  When  pink,  practically 
no  change  is  noticeable.  When  red,  it  is  appreciably  weakened, 
which  may  amount  to  10  to  20  per  cent,  of  its  strength.  When  brown 
with  a  precipitate,  it  should  not  be  used,  although  may  still  retain 
some  activity. 

When  used  for  surgical  purposes  during  these  color  changes  and 
injected  within  the  tissue,  it  may  be  used  as  long  as  the  color  change  is 
no  greater  than  a  light  red;  but  when  it  becomes  brown,  it  should 
never  be  used,  as  it  is  practically  inert  as  a  vaso-constrictor  and  may 
produce  decided  irritation. 

The  following  chemical  test  given  by  Beckwith  may  at  times  be 
useful : 

"A  rough  qualitative  test,  to  show  the  presence  of  active  adrenalin 
in  the  commercial  solution  of  adrenalin  chlorid  of  the  composition 
already  stated,  is  based  on  its  conduct  with  ferric  chlorid.  As  you 
are  aware,  ferric  chlorid  gives  striking  and  more  or  less  characteristic 
color  reactions  with  many  of  the  phenols.  Catechol,  the  parent 
phenol  of  adrenalin,  gives  in  dilute  aqueous  solution  with  a  very  little 
dilute  ferric  chlorid  solution,  a  brilliant  green  color,  which  upon  care- 
ful addition  of  very  dilute  alkali,  passes  through  a  series  of  color 
changes  from  bluish-green  to  purple-red.  Under  like  conditions, 


142  LOCAL   ANESTHESIA 

adrenalin  acts  similarly.  The  catechol  nucleus  is  responsible  for  this 
reaction,  so  that  it  is  not  peculiar  to  adrenalin.  If,  however,  dilute 
solutions  of  catechol  and  adrenalin  chlorid  be  treated  with  a  little 
very  dilute  ferric  chloride  solution  without  subsequent  addition  of 
alkali,  and  if  the  two  solutions  be  allowed  to  stand  in  the  air  for  some 
minutes,  a  difference  in  their  behavior  will  manifest  itself.  In  the 
case  of  catechol,  the  green  color  persists;  in  that  of  adrenalin,  it 
changes  slowly  to  pink  or  red.  While  the  test  is  not  absolutely  final, 
it  is  fair  to  conclude  that  a  commercial  solution  of  adrenalin  chlorid 
retains  some  activity  when  a  sample,  highly  diluted,  gives  with  a  drop 
of  very  dilute  ferric  chlorid  solution  a  green  color  changing  soon  to 
pink  or  red.  Many  foreign  substances  interfere  with  the  test,  so  that 
it  may  not  be  applicable  to  adrenalin  in  mixtures." 

Solutions  of  adrenalin  chlorid  are  injuriously  affected  by  many 
substances.  Besides  air  and  light,  alkalies  oxidizing  agents  and  iron 
are  particularly  to  be  avoided,  while  nearly  all  acids  are  harmless. 
The  alkali  contained  in  glass  bottles  may  at  times  be  a  source  of  de- 
terioration and  should  be  guarded  against  by  obtaining  as  nearly  as 
possible  an  alkali-free  glass  and  by  keeping  the  solution  acid  which 
should  always  contain  ^{QQ  of  i  per  cent.  C.  P  hydrochloric  acid. 

Stoppers  for  bottles  should  preferably  be  of  glass  and  when  cork 
is  used,  it  should  be  protected  by  some  impervious  material. 

Physiologic  Action. — The  part  of  the  physiologic  action  of  adren- 
alin which  concerns  us  here  is  limited  to  its  action  upon  the  circulation 
in  any  given  operative  area  when  locally  used.  For  a  consideration 
of  its  highly  interesting  action  in  other  spheres  of  its  influence,  particu- 
larly its  constitutional  effect  in  its  many  clinical  uses,  the  reader  is 
referred  to  the  various  articles  which  deal  with  this  subject.  (See' 
especially  Crile,  Boston  Med.  and  Surg.  Jour.,  March  5,  1903,  and 
Amer.  Jour.  Med.  Sciences,  April,  1909;  Miles  and  Muhlberg,  Cleve- 
land Med.  Jour.,  Dec.,  1902;  also  Winters,  Lancet,  June,  1905,  and 
others.) 

Only  such  clinical  illustrations  will  be  mentioned  here  as  will  serve 
to  emphasize  its  great  power  as  a  vasoconstrictor,  and,  under  certain 
conditions,  a  stimulant  to  all  smooth  muscle-fibers. 

The  action  of  adrenalin  in  constricting  the  blood-vessels  is  both 
local  and  constitutional;  the  latter  effect  is  quite  general  throughout 
the  body;  its  local  effect  is  best  studied  when  injected  locally  in  dilute 
solutions,  when  it  produces  a  high  degree  of  anemia  of  marked  dura- 
tion; that  portion  of  the  drug  absorbed  exercises  a  constitutional  effect. 
Lehman  found  that  by  injecting  solutions  of  adrenalin  into  the  liver 


ADRENALIN  143 

of  experimental  animals  he  was  enabled  to  excise  large  sections  of  this 
organ  without  loss  of  blood ;  this  marked  anemia  lasted  thirty  to  forty 
minutes  and  was  not  followed  by-  secondary  hemorrhage.  This 
vasoconstrictor  action  does  not  seem  to  depend  upon  any  influence 
upon  the  vasomotor  nerves,  but  is  no  doubt  due  to  direct  action  upon 
the  smooth  muscle-fibers  in  the  vessel  walls,  as  shown  by  the  follow- 
ing experiments.  Crile  was  able  to  keep  the  heart  of  a  decapitated 
dog  acting  for  over  ten  hours  by  the  action  of  adrenalin  and  saline 
solution  upon  the  heart  and  blood-vessels,  and  in  sufficient  dosage 
to  be  able  to  produce  a  marked  rise  in  blood-pressure  even  when 
the  vasomotor  center  was  proved  to  have  been  exhausted  (complete 
shock) ;  the  same  result  was  produced  when  the  center  was  cocainized 
or  had  previously  been  destroyed;  it  also  occurred  after  the  division 
of  both  vagi  and  both  accelerantes  when  the  animal  was  under  the  in- 
fluence of  curare.  It  was  also  noted  during  these  experiments  that 
adrenalin  was  capable  of  constricting  the  blood-vessels  after  the  circu- 
lation had  ceased. 

Animals  killed  by  asphyxia,  and  apparently  dead  for  periods  up 
to  fifteen  minutes,  were  restored  to  conscious  life  again  by  artificial 
respiration  and  the  simultaneous  injection  into  the  jugular  vein  of 
adrenalin  and  salt  solution. 

The  circulation  and  respiration  of  dogs  electrocuted  by  a  shock 
of  230x3  volts  of  an  alternating  current  were  again  re-established  by 
injecting  adrenalin  solution  into  the  circulation. 

During  these  experiments  it  was  determined  that  adrenalin  was 
rapidly  oxidized  by  the  solid  tissues  of  the  body  as  well  as  by  the  blood. 

Animal  experimentation  conducted  by  writers  under  slightly  dif- 
ferent conditions  showed  similar  results. 

From  these  and  similar  experiments  it  is  concluded  that  the  action 
is  a  direct  one  exercised  upon  the  smooth  muscle-fibers  in  the  vessel 
walls;  all  smooth  muscle-fibers  seem  influenced  in  a  similar  way, 
though  not  always  to  the  same  degree  (Jacoby  and  Schafer).  It  is 
found  to  exert  a  marked  influence  upon  the  uterine  muscles,  as  illus- 
trated in  a  case  of  Cesarean  section  operated  on  by  Bogdanovics,  in 
which,  after  the  delivery  of  the  child,  the  uterus  was  found  flabby  and 
inert.  The  uterine  wound  was  first  closed  and  i  c.c.  of  a  i :  10,000 
solution  of  adrenalin  injected  into  the  uterine  walls  at  four  different 
points ;  this  at  once  excited  muscular  action  and  the  contracted  uterus 
became  as  hard  as  stone. 

The  blood-vessels  of  the  different  organs  are  not  all  influenced  to 
the  same  degree ;  the  action  on  the  vessels  of  the  skin  is  most  marked, 


144  LOCAL  ANESTHESIA 

less  so  in  the  gastro-intestinal  tract  and  bladder,  and  hardly  at  all  in 
the  vessels  of  the  lungs  (Langley).  The  urine  of  animals  injected 
with  large  doses  of  adrenalin  is  capable  when  injected  into  other 
animals  of  raising  the  blood-pressure;  but  it  would  seem  that  this 
agent  is  very  largely  destroyed  in  the  body,  very  little  of  it  being  ex- 
creted. Ott  and  Harris,  Meltzer  and  Auer  found  that  by  mixing 
strychnin  with  adrenalin  before  injection  into  frogs  the  toxic  action 
is  both  delayed  and  diminished;  this  observation  is  of  great  practical 
value  in  local  anesthesia,  as  will  be  presently  pointed  out. 

A  similar  favorable  action  of  adrenalin  has  been  noted  in  the  treat- 
ment of  snake-bite  in  3  cases  recently  reported  by  Drs.  Hooker,  Men- 
ger,  and  Ferguson,  all  occurring  in  the  state  of  Texas.  In  2  cases  the 
snake  was  a  rattler,  in  the  other  case  a  moccasin.  All  bites  were  upon 
the  extremities,  and  occurred  from  one  to  two  hours  before  treatment. 
Various  procedures  were  resorted  to — scarification  or  incisions  into 
the  wound,  injections  of  permanganate,  with  the  use  of  a  constrictor 
reported  in  i  case — but  all  were  treated  with  adrenalin  in  addition, 
injected  into  the  tissues  near  the  site  of  the  bite.  All  cases  recovered 
in  a  short  time  without  any  notable  local  or  constitutional  after- 
effect; the  adrenalin  was  largely  given  the  credit  for  their  favorable 
termination.  It  is  probable  that  in  these  cases  the  adrenalin, 
through  its  vasoconstriction,  retains  the  snake  venom  in  the  parts 
locally  until  it  is  largely  oxidized  or  destroyed  by  action  upon  it  of  the 
tissues. 

Dr.  K.  C.  Bose,  of  Calcutta,  gives  his  experiences  in  the  treatment 
of  enlarged  spleens,  where  he  claims  invariably  satisfactory  results. 
Tremendous  enlargements  have  yielded  to  5 -drop  doses  three  times  a 
day,  continued  for  a  period  of  several  weeks.  Interesting  and  some- 
what similar  experience  was  reported  by  Dr.  Tarry,  of  Long  Beach, 
Miss.  Another  practical  clinical  application  of  adrenalin,  which 
illustrates  in  a  striking  way  its  local  action  upon  the  vascularity  or 
congestion  of  a  part,  is  readily  seen  in  urethral  stricture,  particularly 
of  the  deep  urethra;  tight  strictures  of  these  parts,  when  it  seems  al- 
most impossible  to  pass  even  a  filiform,  if  first  treated  with  adrenalin 
(about  5  to  10  drops  of  a  1:5000  solution),  deposited  in  the  urethra 
with  an  urethral  instillator  just  in  front  of  the  structure  and  allowed  to 
remain  about  ten  minutes,  will  often  so  relieve  the  congestion  of  the 
parts,  as  to  easily  permit  the  passage  of  a  moderate-sized  instrument. 
Further  clinical  applications  could  be  enumerated  in  great  numbers, 
but  the  above  will  suffice  to  illustrate  its  highly  valuable  local  action 
as  a  vasoconstrictor. 


ADRENALIN  145 

Before,  however,  concluding  these  illustrations  a  few  remarks  may 
"be  made  regarding  its  highly  beneficial  and  useful  action  in  certain 
rectal  conditions,  notably  hemorrhoids.  In  this  condition,  when  the 
parts  are  badly  swollen  and  congested,  which  increases  their  irritabil- 
ity, marked  relief  may  be  obtained  subjectively  and  objectively  by 
the  use  of  adrenalin,  either  alone  or  combined  with  other  indicated 
agents  in  ointment  form,  this  relives  the  congestion,  causing  the  parts 
to  shrink  and  assume  a  more  normal  aspect. 

In  all  operations  upon  these  parts  when  they  are  badly  congested 
and  bleed  freely,  either  under  general  or  local  anesthesia,  the  injection 
of  adrenalin  solution  is  always  of  decided  benefit;  under  general  an- 
esthesia the  injection  of  a  few  syringefuls  of  a  solution  of  10  drops 
to  the  ounce  distributed  in  the  field  will  prove  of  decided  aid. 

Hurter  and  Richards,  as  well  as  others,  have  demonstrated  that 
this  agent  in  large  doses  or  when  repeatedly  used  will  produce  a 
glycosuria. 

Vincent  claims  that  this  agent  is  a  muscle  poison,  death  resulting 
from  the  use  of  large  doses  by  paralysis  of  respiration  with  small 
weak  pulse,  which  follows  a  short  period  of  high  blood-pressure. 

The  dose  of  adrenalin  should  be  carefully  considered,  as  large 
doses  are  very  dangerous;  the  greater  the  concentration  the  greater 
the  toxic  action.  In  very  dilute  solutions  a  much  larger  quantity  can 
be  safely  given;  the  toxic  dose  is  naturally  much  smaller  when  given 
intravenously  than  when  subcutaneously  administered. 

Batelle,  Bouchard,  and  Claude  give  the  toxic  intravenous  dose 
for  rabbits  as  o.oooi  to  0.0002  gram  per  kilo,  while  the  subcutaneous 
toxic  dose  is  0.002  to  0.02  per  kilo.  Batelle  states  that  the  toxic  dose 
subcutaneously  is  forty  times  greater  than  the  intravenous. 

The  degree  of  action  of  this  drug  depends  entirely  upon  the 
strength  of  the  solution.  While  a  decided  influence  is  obtained  by 
remarkably  weak  dilutions,  the  use  of  stronger  solutions  will  abso- 
lutely obliterate  the  lumen  of  vessels  the  size  of  the  palmar  digital 
arteries  and  even  larger,  so  that  not  a  drop  of  blood  will  escape  from 
their  cut  ends  while  the  adrenalin  remains  in  action. 

It  is,  however,  never  necessary  for  our  purposes  to  use  strong 
solutions,  as  a  very  decided  influence  is  produced  by  very  dilute  solu- 
tions. Moore  and  Purinton  found  that  the  blood-pressure  of  dogs 
was  noticeably  increased  by  doses  as  small  as  0.000,000,245  to 
0.000,024  gram  of  the  extract  per  kilo  of  dog  weight. 

In  animals  experimented  upon  with  toxic  doses,  after  a  short 
initial  rise  of  blood-pressure,  there  is  a  collapse  of  the  vasomotor 


146  LOCAL  ANESTHESIA 

system  with  small  rapid  and  feeble  pulse,  paralysis  of  the  extremities, 
tonic  and  clonk  spasms,  opisthotonus,  mydriasis,  rapid  respiration, 
edema  of  the  lungs,  anemia  of  the  abdominal  organs,  and  death 
usually  from  paralysis  of  respiration. 

Its  continuous  injection  in  small  doses  produces  in  animals  ex- 
perimented upon  calcareous  degeneration  of  the  heart,  aorta,  and 
great  vessels  with  glycosuria. 

The  experiments  carried  out  by  Braun  with  adrenalin  upon  him- 
self during  1902  are  given  in -his  "Die  Lokal  Anesthesie,"  and  are  as 
follows:  He  injected  under  the  skin  of  his  forearm  adrenalin  solu- 
tion i  :iooo  in  increasing  doses;  with  a  little  over  %  c-c.  constitutional 
symptoms  were  noticeable.  He  states:  "Five  minutes  after  in- 
jection I  had  a  feeling  of  oppression  in  the  breast,  cardiac  palpitation 
with  quickened  and  deepened  respirations;  the  number  of  heart-beats 
rose  from  64  to  94  per  minute.  I  was  compelled  to  lie  down,  al- 
though after  one  and  a  half  minutes  the  symptoms  disappeared ;  there 
was  no  glycosuria.  When  I  diluted  the  adrenalin  solution  with  ten 
times  the  quantity  of  normal  salt  solution,  I  was  able  to  increase  the 
quantity  injected  to  i  c.c.  before  any  effect  was  observed." 

The  pronounced  effect  exercised  by  adrenalin  in  delaying  the 
absorption,  and  consequently  the  constitutional  action  and  excretion 
of  any  substances  or  drugs  injected  into  the  tissues  in  combination 
with  it,  is  best  studied  when  the  adrenal  in  is  used  with  some  agent 
little  or  not  at  all  affected  by  its  passage  through  the  system.  This 
action  is  strikingly  illustrated  by  the  following  experiment  of  Klapp 
with  the  use  of  milk-sugar,  first  carried  out  as  a  control  experiment 
without  adrenalin,  and  later  repeated  under  identical  conditions  with 
the  addition  of  adrenalin. 

A  dog  was  injected  subcutaneously  in  the  region  of  the  back  with 
10  c.c.  of  a  6^  per  cent,  milk-sugar  solution,  and  the  excretion  of  the 
sugar  through  the  urine  studied  from  hour  to  hour.  Three  days 
later  the  same  quantity  of  the  same  solution,  with  the  addition  of  2 
drops  of  adrenalin  i  :iooo,  was  similarly  injected  and  the  excretion  by 
the  kidneys  studied  in  the  same  way. 

A  study  of  Fig.  2  will  give  in  a  schematic  way  the  results  of  this 
experiment.  It  will  be  seen  at  a  glance  that  the  maximum  excretion 
of  sugar  without  adrenalin,  as  indicated  by  the  heavy  line,  begins 
immediately  after  the  injection  and  reaches  its  maximum  intensity 
within  the  first  hour,  when  it  rapidly  falls  off  and  entirely  ceases 
after  the  sixth  hour,  by  which  time  a  total  of  0.569  gram  had  been 
recovered  from  the  urine. 


ADRENALIN 


147 


The  dotted  line  indicates  the  absorption  and  excretion  of  the 
sugar  under  the  local  influence  of  adrenalin,  and  presents  a  striking 
and  interesting  contrast  to  the  former  in  the  following  points :  During 
the  first  hour,  in  which  the  maximum  is  excreted  without  adrenalin, 
absolutely  none  was  recovered  when  the .  adrenalin  was  used,  the 
excretion  not  beginning  until  the  commencement  of  the  second  hour; 
from  this  time  it  slowly  increases,  reaching  its  maximum  at  the  end  of 
the  fifth  hour,  and  that  at  this  maximum  point  of  excretion  the 
amount  was  one-half  that  recovered  during  the  interval  of  maximum 
excretion  without  the  use  of  adrenalin;  further,  that  the  excretion  is 
prolonged  over  a  very  much  longer  period,  as  traces  were  still  found 


fframm.0,20 
0,15 
0,10 
0,05 
0,00 

I 

\ 

v 

I 

\ 

I 

• 

^ 

*•• 

jf 

V 

• 

/ 

..•*' 
..•* 

* 

"\ 

\ 

^•^ 

.•**' 
•••* 

"•-..., 

8  Hours 

Fig.  2. — The  influence  of  adrenalin  on  the  excretion  of  milk-sugar  in  the  urin  following 
its  subcutaneous  injection:  i          without, with  adrenalin,  after  Klapp  (Braun). 

in  the  urine  at  the  end  of  the  eighth  hour,  when  the  observations  were 
discontinued,  after  a  total  of  0.343  gram  had  been  recovered. 

Adrenalin  is  absorbed  very  rapidly  from  highly  vascular  tissues 
such  as  the  face,  nose  and  throat,  and  should  always  be  used  cau- 
tiously in  these  parts  as  it  may  produce  a  sudden  and  marked  rise 
in  blood-pressure  causing  alarming  symptoms. 

The  chief  toxic  symptoms  are  palpitation  of  the  heart,  oppression 
and  often  a  feeling  of  dread  or  alarm,  difficult  respiration  and  a  full- 
ness and  throbbing  in  the  head.  These  symptoms  accompanied  by  a 
rapid  rise  in  blood-pressure  usually  pass  off  in  a  few  minutes  when 
the  drug  should  be  more  cautiously  used,  but  if  protracted  or  alarm- 
ing, agents  which  reduce  the  blood-pressure  such  as  amyl  nitrite  may 
be  used. 

Operators  often  blame  the  local  anesthetic  for  such  symptoms 


148  LOCAL  ANESTHESIA 

occurring  in  the  course  of  an  operation  when  the  adrenalin  is  the 
disturbing  agent. 

SURGICAL  USES 

In  the  strengths  ordinarily  employed  its  use  is  not  followed  by 
any  after-reaction;  there  is  not  hyperemia,  but  the  tissues  gradually 
resume  their  normal  vascularity,  and  there  seems  to  be  no  retarding 
or  injurious  action  upon  the  healing  of  wounds;  w;hen  slightly  more 
than  the  dose  to  be  recommended  has  been  used,  it  has  seemed  to  the 
writer  that  there  was  more  after-pain  in  the  wound  than  would  have 
been  the  case  under  other  conditions  associated  with  a  reactionary 
hyperemia.  If  an  excessive  dose  is  used  there  follows  after  the 
primary  anemia,  which  is  marked  and  prolonged,  a  vaso-motor 
paralysis  during  which  time  the  vessels  remain  dilated  with  open 
mouths  and  secondary  hemorrhages  may  occur.  Following  the  use 
of  excessive  doses  the  resulting  anemia  may  be  so  profound  and  pro- 
longed as  to  lead  to  death  of  the  tissue  with  sloughing. 

As  ordinarily  used  by  the  author  for  infiltration,  the  dose 
should  never  exceed  5  drops  of  a  i  riooo  solution  to  the  ounce  of  the 
anesthetic  fluid,  and  less  than  this,  2  or  3  drops,  will  be  found  amply 
sufficient. 

It  is  well  in  all  large  operations  to  estimate  about  the  total  quan- 
tity of  the  anesthetic  solution  likely  to  be  needed — say,  for  a  rather 
large  hernia,  4  to  6  ounces  may  be  required ;  this  is  measured  off  and 
put  in  a  convenient  receptacle,  and  to  this  total  quantity  about  15 
or  20  drops  of  the  adrenalin  solution  (i :  1000)  is  added;  in  this  way 
we  know  exactly  how  much  is  being  used  and  the  safe  dose  need  not 
be  exceeded;  we  obtain  by  these  weak  dilutions  all  that  can  be  ac- 
complished by  stronger  doses,  and  without  noticeable  constitutional 
action  or  other  ill  effects.  As  the  action  of  adrenalin  is  immediate  it 
is  not  necessary  to  wait  to  obtain  this  influence,  but  a  delay  of  five 
to  ten  minutes  is  usually  necessary  after  the  infiltration  to  obtain  the 
full  anesthetic  effect  of  the  drug  used.  When  the  incision  is  made  the 
first  effect  noticed  will  be  the  anemia  of  the  parts,  practically  no  blood 
being  lost  except  from  the  mouths  of  divided  vessels.  When  adren- 
alin is  used  in  the  above-mentioned  strength  this  anemia  lasts  approxi- 
mately one  hour;  this  is  influenced  to  a  considerable  extent  by  the 
normal  vascularity  of  the  part;  it  is  consequently  of  shorter  duration 
about  the  face  and  in  abnormally  vascular  parts;  in  these  parts  the 
maximum  dose,  5  drops  to  the  ounce  of  anesthetic  solution,  may  be 
found  necessary. 


ADRENALIN  149 

The  advantages  of  this  anemia  are  the  greater  facility  and  free- 
dom with  which  delicate  dissections  may  be  performed  in  a  compara- 
tively bloodless  field.  Aside  from  the  hemostasis,  the  most  notable 
gain  derived  from  the  use  of  adrenalin  is  its  power  to  retain  the  anes- 
thetic agent  within  the  tissues  for  a  considerable  length  of  time,  from 
three-quarters  of  an  hour  to  an  hour  and  a  half  in  the  strength  above 
mentioned  (not  over  5  drops  to  the  ounce  of  solution) ;  when  stronger 
solutions  are  used  this  anemia  and  prolongation  of  the  anesthetic 
action  of  the  agent  used  may  be  considerably  extended — as  long  as 
three  or  four  hours  in  some  cases. 

This  retention  within  the  tissues  intensifies  the  anesthetic  action 
and  lessens  the  likelihood  of  repeated  injections  being  necessary  in  a 
prolonged  operation.  When  adrenalin  is  used  the  trauma  of  repeated 
infiltrations  upon  the  tissues  is  avoided  and  the  possible  toxic  action 
of  such  constant  infiltrations  is  eliminated.  The  likelihood  of  any 
toxic  action  developing,  is  lessened,  even  if  the  solution  injected  be 
retained  in  the  tissues  a  long  period  of  time.  When  absorption  does 
occur  it  is  so  gradual  that  no  constitutional  effects  are  to  be  noted. 
This  permits  the  use  of  much  more  extensive  infiltrations  than  would 
otherwise  be  safe  without  the  addition  of  adrenalin;  in  this  way  we 
have  repeatedly  made  use  of  8,  10,  12  or  more  ounces  of  Schleich 
solution  No.  i,  or  our  solution  No.  i,  in  extensive  operations  without 
once  having  seen  any  toxic  effects  arising  from  the  large  quantity 
used.  Of  course,  in  all  operations  under  infiltration  a  certain  vari- 
able quantity  of  the  solution  infiltrated  escapes  through  the  incisions, 
which  to  some  extent  lessens  the  total  amount  of  the  drug  finally 
absorbed. 

Ordinarily,  in  operations  upon  the  peripheral  parts  of  the  ex- 
tremities under  local  anesthesia,  with  the  addition  of  adrenalin,  the 
constrictor  may  often  be  dispensed  with,  except  for  hemostatic  con- 
trol of  the  larger  vessels,  as  in  amputations,  when  it  should  always  be 
used.  When  used  in  these  operations  it  should  always  be  applied 
after  the  infiltration  or  nerve-blocking  has  been  completed;  in  the 
case  of  the  latter  procedure  it  may  be  necessary  to  apply  it  below  the 
point  of  the  nerve  injection,  but  in  case  of  infiltrations  it  should  al- 
ways be  applied  proximal  to  the  field  of  infiltration.  When  used  in 
this  way  with  adrenalin  it  intensifies  both  the  action  of  the  adrenalin 
as  well  as  that  of  the  local  anesthetic  used  (the  anesthesia  is  probably 
also  contributed  to  by  the  fact  that  anemic  tissues  are  always  less 
sensitive  than  vascular),  and  prolongs  indefinitely  the  local  anesthetic 
action  of  the  agent  used  as  well  as  the  adrenalin.  This  prolongation 


LOCAL   ANESTHESIA 


of  the  action  of  these  agents  in  this  way  is  only  limited  by  the  time 
that  the  constrictor  may  safely  be  allowed  to  remain  in  position  (from 
one  to  two  hours,  depending  upon  the  age  of  the  patient  and  condition 
of  the  parts  locally).  A  very  important  point  in  the  technic  in 
operating  in  any  field  with  the  use  of  adrenalin  is  to  make  ample 
provision  for  hemostasis  after  the  effects  of  the  adrenalin  have  sub- 
sided :  bleeding  points  which  barely  permit  a  capillary  ooze  at  the  time 
of  operation  may,  after  the  vasoconstriction  subsides,  give  rise  to  a 
rather  free  hemorrhage;  for  this  reason,  it  is  absolutely  necessary  to 


100 


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30 


60        W         60        90       JOO      //ff       J20      /JO 


Fig.  3. — Illustrating  diagrammatically  the  action  of  adrenalin  in  combination  with 
different  anesthetics  (after  La  wen) :  A,  Adrenalin;  B,  adrenalin  with  cocain;  C,  adrenalin 
with  eucain;  D,  adrenalin  with  tropococain  (Braun). 

secure  and  ligate  all  visible  bleeding  points,  and  leave  no  dead  spaces 
for  the  accumulation  of  hematomas;  this  may  be  accomplished  by 
approximating  the  different  planes  of  tissues,  as  in  a  herniotomy, 
by  anchoring  the  overlying  plane  to  the  one  beneath  by  occasionally 
passing  the  suture  down  and  catching  a  bite  in  the  plane  beneath, 
thus  uniting  the  various  layers  at  the  suture  line  and  preventing  a 
possible  space  for  the  accumulation  of  ooze.  In  operating  upon  very 
loose  tissues,  as  the  scrotum,  it  is  very  essential  to  finish  the  operation 
by  a  firm  supporting  dressing,  held  snugly  in  place  by  a  well-fitting 


ADRENALIN  151 

suspensory.  In  operations  within  the  nasal  cavity,  and  in  such 
wounds  as  are  left  open,  postoperative  bleeding  should  be  guarded 
against  by  the  proper  use  of  packs. 

All  the  agents  in  use  as  local  anesthetics  are  not  equally  affected 
by  adrenalin ;  this  degree  of  influence  varies  with  the  different  agents. 

Beta-eucain  is  affected  to  a  less  extent  than  cocain  and  the  same 
with  stovain,  while  with  tropococain  it  has  little  or  no  effect.  Novo- 
cain  is  decidedly  affected,  its  action  being  greatly  intensified  and 
prolonged  by  the  addition  of  adrenalin. 

Other  effects  noticed  by  these  combinations  are  that  when  used 
with  cocain,  which  has  a  slight  vasoconstrictor  effect,  the  resulting 
anemia  is  slightly  more  marked  than  with  such  agents  as  novocain 
(Fig.  3). 

Large  operative  fields  can  be  rendered  completely  bloodless  by 
its  use;  here  it  is  not  necessary  to  thoroughly  saturate  the  entire  field 
with  the  solution,  but  to  make  the  injections  in  a  peripheral  or  cir- 
cumferential manner  around  the  field,  as  with  the  Hackenbruch  plan 
for  local  anesthesia,  or  only  in  the  directions  from  which  the  circula- 
tion enters,  thus  constricting  all  vessels  which  enter  the  operative 
area ;  this  use  of  the  agent  may  often  be  of  value  when  operating  upon 
very  vascular  areas  even  under  general  anesthesia. 

To  obtain  this  perfect  anemia  in  operating  upon  the  extremities, 
unless  at  the  extreme  distal  parts,  it  will  be  necessary  to  make  the 
injections  on  the  distal  as  well  as  the  proximal  side  of  the  field,  to 
influence,  on  the  one  hand,  the  veins;  on  the  other,  the  arteries  as 
they  enter  the  field. 

The  synthetic  preparations,  such  as  arterenin,  homorenon,  and 
suprarenin  synthetic,  are  found  to  be  identically  the  same  in  formula 
and  action  as  adrenalin.  Braun  found  that  homorenon  was  about 
fifty  times  less  toxic  and  fifty  times  less  active  than  adrenalin,  and 
does  not  cause  any  injury  or  irritation  to  the  tissues. 

The  synthetic  preparations  of  adrenalin  have  until  recently  been 
little  used  in  this  country,  surgeons  preferring  the  natural  product, 
which  had  so  far  proved  best  and  has  answered  all  requirements ;  all 
that  the  synthetic  chemists  have  attempted  is  to  imitate  adrenalin, 
none  have  surpassed  it.  The  comparison  of  these  synthetic  prepara- 
tions with  adrenalin  has  been  undertaken  by  some  observers,  thus, 
Biberfeld  states  that  synthetic  suprarenin  is  identical  both  by  quali- 
tative and  quantitative  test  with  the  natural  preparation,  while 
arterenin  seemed  slightly  weaker,  at  least  in  rabbits,  the  toxic  dose 
being  two  or  three  times  greater.  Braun,  who  has  experimented  with 


152  LOCAL   ANESTHESIA 

both  solutions,  finds  them  in  1:1000  dilutions  about  equal  to  the 
natural  preparations;  both  preparations  possess  certain  qualities  in 
common  with  the  natural  preparation;  they  must  be  kept  in  slightly 
acid  solutions  (HC1) ;  they  have  but  a  limited  stability,  and  must  not 
be  used  when  cloudy  or  discolored.  Regarding  the  synthetic  prepara- 
tions of  homorenon  Braun  has  much  to  say  in  favor  of  it;  it  is  quite 
soluble  and  stable  and  presents  identical  pharmacologic  qualities  with 
adrenalin,  but  about  fifty  times  weaker  in  action  and  fifty  times  less 
toxic.  A  5  per  cent,  homorenon  solution  is,  therefore,  equal  to  a 
i :  1000  solution  of  adrenalin,  and  produces  a  vasoconstriction  equal 
to  that  of  corresponding  strength.  When  used  intracutaneously  and 
subcutaneously  it  produces  no  irritation  or  after-reaction. 

That  ideal  synthetic  preparations  of  the  adrenal  glands  will 
eventually  be  obtained  which  will  entirely  replace  the  animal  ex- 
tracts is  to  be  expected,  as  has  been  the  case  with  local  anesthetics, 
novocain  representing  the  greatest  and  latest  achievement  in  this  line. 

The  animal  extracts  have  many  disadvantages,  principally  their 
lack  of  stability,  inconstancy  of  action,  the  inability  to  properly 
sterilize  them  by  heat,  and  their  cost,  which,  when  considered  with 
their  poor-keeping  qualities,  makes  this  cost  relatively  greater. 

The  latest  achievements  in  synthetic  adrenalin  is  suprarenin 
synthetic;  this  agent  has  now  been  very  thoroughly  tested,  and  seems 
to  meet  all  requirements  and  demands  made  upon  it.  In  i :  1000 
solution,  as  ordinarily  used,  its  rapidity,  intensity,  and  duration  of 
action  compare  very  favorably  with  the  natural  product,  some  ob- 
servers claiming  for  the  synthetic  product  slight  advantages. 

It  is  further  capable  of  a  fair  degree  of  sterilization  by  heat  (boiling 
from  three  to  five  minutes) ;  it  is  more  stable  in  keeping  qualities  and 
is  cheaper. 

While  the  writer  has  had  but  a  limited  experience  with  this  prepa- 
ration the  reports  from  others  are  rather  encouraging,  and  it  gives 
promise  of  fulfilling  all  requirements  exacted  of  it,  and  will,  if  further 
experience  justifies  these  claims,  largely,  if  not  entirely,  replace  the 
organic  preparations. 

The  following  experiments,  reported  by  Braun  in  his  book  on  local 
anesthesia,  should  be  compared  with  similar  experiments  made  by  the 
same  author  with  similar  solutions,  but  without  the  addition  of 
adrenalin,  and  quoted  on  page  87.  (See  chapter  on  Local  Anes- 
thetics.) 

"  i .  To  100  c.c.  of  a  i  per  cent,  alypin  solution  5  drops  of  adrenalin 
(1:1000)  were  added.  With  this  solution  an  intradermal  wheal  is 


ADRENALIN  153 

formed;  the  injection  is  painful.  No  hyperemia  occurs,  but  the 
adrenalin  anemia  develops  to  full  extent.  The  white  wheal  lies  with- 
in an  area  covered  with  large  white  blotches.  The  anesthesia  lasts 
for  about  two  hours,  when  the  sensibility  gradually  returns.  An 
hyperemic  infiltrate  remains  at  the  point  of  injection  until  next  day. 

"2.  0.5  per  cent,  solution,  with  the  addition  of  0.8  per  cent, 
sodium  chlorid;  i  c.c.  of  this  solution,  to  which  has  been  added  i  drop 
of  i :  1000  adrenalin,  is  injected  in  a  circular  manner  into  the  subcu- 
taneous tissue  at  the  base  of  the  fourth  finger. 

''The  injection  is  painful;  after  ten  minutes  the  entire  finger  as 
far  as  the  tip  is  entirely  anesthetic.  After  two  hours  the  sensibility 
begins  to  gradually  return,  and  after  three  hours  is  completely 
normal. 

"The  base  of  the  finger  remains  red,  infiltrated,  and  painful  for 
several  days;  0.5  per  cent,  cocain  or  eucain  solution  with  the  same 
addition  does  not  produce  this  final  phenomena. 

"3.  i  per  cent,  iso tonic  novocain  solution  and  5  drops  of  adrenalin 
solution  (i :  1000)  to  each  100  c.c.  The  formation  of  cutaneous 
wheals  on  the  forearm  by  intradermal  injections  were  painless  and 
produced  a  very  pronounced  anemia.  The  duration  of  the  anesthesia 
lasted  longer  than  an  hour  and  left  no  reaction. 

"4.  i  per  cent,  novocain  solution  with  2  drops  of  i :  1000  adrenalin 
to  each  cubic  centimeter.  Formation  of  wheals  on  the  forearm; 
injection  painless.  The  anesthesia,  which  extended  considerably 
beyond  the  limits  of  the  wheal,  lasted  about  four  hours.  The  action 
of  the  adrenalin  is  very  marked. 

"After  subsidence  of  the  adrenalin  anemia  some  after-pain  results 
at  the  site  of  injection.  No  other  reaction. 

"  5-  M  c-c-  of  the  same  novocain-adrenalin  solution  was  injected 
subcutaneously  in  the  forearm.  The  skin  over  the  point  of  injection, 
as  well  as  the  distribution  of  the  sensory  nerves  which  passed  through 
the  injected  area,  was  insensitive  to  pain  for  from  two  and  a  half  to 
three  hours.  Pronounced  adrenalin  influence.  No  reaction. 

"6.  0.5  per  cent,  novocain  solution  with  the  addition  of  i  drop  of 
adrenalin  (i :  1000)  to  each  cubic  centimeter;  i  c.c.  of  this  mixture  was 
injected  subcutaneously  in  a  circular  manner  around  the  base  of  the 
fourth  finger.  After  ten  minutes  the  entire  finger  is  anemic  and 
insensitive. 

"After  sixty-five  minutes  sensation  begins  to  return  in  the  finger- 
tip, requiring  a  full  hour  for  the  complete  return  of  sensation.  There 
was  no  after-pain  or  swelling." 


154  LOCAL  ANESTHESIA 

In  conclusion,  a  few  words  regarding  the  dose  of  adrenalin:  10 
minims  is  about  the  safe  maximum  dose  which  should  be  thrown  into 
the  circulation  of  a  normal  healthy  adult  at  any  one  time,  but  as  the 
dose  varies  with  the  concentration  this  amount  may  be  exceeded 
when  largely  diluted  and  distributed  over  a  large  area,  as  in  infiltra- 
tion, from  which  it  will  be  slowly  taken  up.  The  dose  should  vary 
according  to  the  age  and  condition  of  the  patient;  childhood,  old  age, 
arteriosclerotics,  and  those  suffering  from  lesions  of  the  vascular 
system,  high  blood-pressure,  Graves'  disease,  diabetes,  etc.,  are  more 
susceptible  to  its  influence.  The  dose  in  these  cases  should  be  less- 
ened accordingly. 


CHAPTER  VIII 

PRINCIPLES  OF  TECHNIC 
GENERAL  CONSIDERATIONS 

IN  considering  in  its  broadest  sense  the  advisability  or  utility  of 
performing  major  operations,  under  purely  local  methods  of  anes- 
thesia, as  opposed  to  the  use  of  cerebral  anesthetics,  one  must  con- 
sider primarily  the  risk  to  the  life  of  the  patient. 

Notwithstanding  the  many  advances  that  have  been  made  in  the 
administration  of  general  anesthetics,  particularly  in  the  adminis- 
tration of  ether  by  the  open  method,  the  risk  from  general  anesthetics 
remains  relatively  high.  Many  well-appointed  institutions,  where 
the  anesthetics  are  given  by  professional  anesthetists,  are  able  to  pre- 
sent large  series  of  cases,  10,000  to  15,000,  without  a  death.  These 
are  exceptional  illustrations,  and  cannot  be  accepted  as  representing 
the  average  conditions  which  prevail  in  the  great  majority  of  insti- 
tutions, or  which  occur  during  the  administration  of  anesthetics  out- 
side of  institutions. 

We  had  been  led  to  believe  that  due  to  our  improved  methods  and 
the  diffusion  of  knowledge  regarding  the  administration  of  anes- 
thetics, the  mortality  had  been  very  materially  lessened  of  late. 
This  has  been  largely  dissipated  by  the  report  of  Neuber  to  the  Surg- 
ical Congress  of  1909,  in  which  he  shows  that  the  mortality  remains 
about  what  it  was  many  years  ago.  Many  of  the  more  recent  statis- 
tics published  represent  results  in  large  surgical  centers,  where  the 
administration  of  anesthetics  is  largely  in  the  hands  of  experts  and 
cannot  be  accepted  as  representing  the  general  results.  Neuber  col- 
lected many  thousands  of  cases  (previously  published  and  unpub- 
lished) ,  and  was  able  to  show  that  the  deaths  from  chloroform  average 
i  to  2060  and  those  from  ether  i  to  5930,  thus  raising  the  mortality 
to  about  where  it  stood  a  decade  ago. 

"In  view  of  the  preceding  fact,  is  it  not  proper  that  while  we  are 
seeking  by  every  means  suggested  by  reason,  ingenuity,  and  experi- 
ence to  minimize  the  dangers  of  these  necessary  evils — general  an- 
esthetics— that  we  also  continue  to  develop  and  perfect  the  various 
methods  of  local  and  regional  anesthesia,  which  permit  us  to  accom- 
plish the  same  results  without  peril  to  the  organism  or  injury  to  the 
part  involved?  If  this  great  desideratum  can  be  realized  in  a  con- 


156  LOCAL    ANESTHESIA 

stantly  increasing  number  of  surgical  conditions  by  a  skilful  and 
judicious  application  of  cocain  and  its  succedanea,  why  not  resort  to 
these  methods  of  tener  whenever  they  can  be  advantageously  applied 
and  thus  help  to  eliminate,  or  at  least  diminish,  one  of  the  greatest 
sources  of  anxiety  in  surgical  practice?"  (Matas). 

Admitting  that  local  methods  of  anesthesia  possess  certain  disad- 
vantages to  the  operator,  in  view  of  the  increased  time  required  and 
the  greater  attention  often  necessary  to  bestow  upon  the  patient, 
such  methods  of  operating  will  always  be  unpopular  in  very  large 
clinics,  where  a  large  number  of  cases  are  operated  daily;  still  the  ad- 
vantages to  the  patient  are  often  so  great  as  to  make  local  methods  of 
operating  the  method  of  choice  in  many  cases. 

To  the  great  majority  of  operators,  whose  patients  are  brought 
into  the  operating-room  before  being  anesthetized  while  the  opera- 
tor waits  the  completion  of  anesthesia,  this  loss  of  time  is  unnecessary 
with  local  anesthesia,  as  the  operator  may  begin  the  anesthetizing 
process  at  once,  and  with  many  of  the  commoner  performed  opera- 
tions the  actual  time  spent  in  the  operating-room  is  no  greater  than 
under  general  anesthesia. 

We  must  also  face  the  broad  proposition  of  whether  or  not  it  is 
desirable  that  the  patient  retain  consciousness  during  the  perform- 
ance of  the  operation.  Obviously,  if  we  took  the  view  that  such  con- 
sciousness was  wholly  undesirable,  except  in  minor  operations,  it 
would  be  a  serious  objection  to  local  anesthesia,  but  such  is  not  the 
case,  particularly  where  small  doses  of  morphin  and  scopolamin  are 
used  beforehand,  as  we  advocate  in  all  major  procedures,  which  allays 
anxiety  and  uneasiness.  There  are  many  patients  who  dread  more 
than  anything  else  the  loss  of  consciousness,  and  many  who  having 
once  had  a  general  anesthetic  do  not  care  to  repeat  the  experience. 

The  great  majority  of  our  cases  operated  under  local  anesthesia 
come  to  us  especially  for  this  purpose,  and  many  operators  are  able 
to  attract  a  large  clientele  by  the  skilful  development  of  purely  local 
methods  and  prefer  local  anesthesia  for  all  suitable  cases.  Kohler 
almost  invariably  uses  it  for  the  removal  of  the  thyroid  gland.  Cer- 
tain other  desiderata  are,  however,  essential,  besides  a  knowledge  of 
the  purely  technical  procedures;  these  are,  first  of  all,  a  thorough 
knowledge  of  the  nerve-supply  of  the  part;  local  anesthesia  makes  of 
the  surgeon  especially  a  nerve  anatomist;  other  essentials  are  gentle- 
ness and  patience  on  the  part  of  the  operator;  rough  handling  and 
gross  dissections,  often  indulged  in  under  general  anesthesia,  should 
be  avoided  here. 


PRINCIPLES    OF   TECHNIC  157 

By  employing  a  methodical  plan  of  procedure,  identical  in  all 
cases,  and  developing  and  studying  this  method  with  a  view  of  short- 
ening the  time  consumed  while  maintaining  or  increasing  the  effi- 
ciency should  be  the  object  of  all  who  employ  local  and  regional 
methods  as  a  routine  procedure.  By  employing  this  plan  the  time 
consumed  is  little  in  excess  of  that  needed  for  the  performance  of  the 
same  operation  under  general  anesthesia  and  may  often  compare  very 
favorably  with  it.  Aside  from  selecting  a  quick  and  effective  method 
of  anesthesia  and  operation  much  time  can  be  saved  by  making 
as  many  injections  and  infiltrating  as  much  of  the  field  as  possible 
before  beginning  the  operation;  occasionally  the  entire  field  can  be 
blocked,  but  where  this  cannot  be  done  an  effort  should  be  made  to 
carry  this  to  some  definite  stage  and  when  the  operative  procedure 
has  advanced  as  far  as  the  anesthesia,  additional  planes  injected  or 
other  nerve-trunks  blocked,  and  while  waiting  for  these  last  injec- 
tions to  become  effective  the  time  is  utilized  by  ligating  all  necessary 
points  thus  saving  any  actual  loss  of  time.  This  plan  of  procedure 
is  well  illustrated  in  the  operations  for  hernia  and  varicose  veins. 

"We  are  also  convinced  that  an  unfounded  and  unjustifiable 
skepticism  still  prevails  among  many  excellent,  skilful,  and  other- 
wise progressive  surgeons,  who,  having  neither  the  inclination  nor  the 
patience  needed  to  acquire  the  latest,  most  advanced,  and  efficient 
methods  of  local  anesthesia,  or  still  confusing  the  imperfect  and 
dangerous  methods  of  the  past  with  the  safe  and  efficient  methods 
of  the  present,  still  doubt  and  cling  to  general  narcosis  as  the  only 
means  of  abolishing  pain  in  their  operations.  Others,  again,  who 
have  not  familiarized  themselves  with  the  more  recent  applications 
of  regional  anesthesia  in  major  surgery  will  occasionally  perform 
minor  or  superficial  operations,  such  as  the  removal  of  a  wart  or  the 
opening  of  an  abscess,  but  will  smile  with  incredulity  if  in  a  case  re- 
quiring the  amputation  of  a  limb  some  one  suggests  the  propriety  of 
using  cocain  as  the  anesthetic.  There  is  still  a  lingering  tendency  on 
the  part  of  many  surgeons,  and  especially  the  more  conservatively 
inclined  of  the  past  generation,  to  regard  those  who  practice  local 
anesthesia  in  major  surgery  in  the  light  of  experimentalists  or  enthu- 
siasts, and  to  class  them,  as  a  whole,  among  the  impractical  class  of 
surgeons.  To  dispel  this  illusion,  and  to  demonstrate  that  the  value 
and  efficiency  of  cocain  and  its  allies  are  not  restricted  to  the  purely 
minor  or  superficial  cases  that  occur  in  surgical  practice,  but  that 
they  are  still  of  greater  service  in  dealing  with  many  of  the  gravest 
and  most  critical  emergencies  of  surgery,  in  which  the  role  of  the 


158  LOCAL  ANESTHESIA 

anesthetic  is  of  paramount  importance,  will  be  the  object  of  our  en- 
deavor in  this  volume"  (Matas). 

We  must  also  consider  that  had  the  discovery  of  local  anesthesia 
preceded  instead  of  followed  that  of  general  anesthesia,  it  would  cer- 
tainly have  now  been  established  on  a  firmer  foundation  and  its 
principles  more  generally  understood,  instead  of  having  to  contest 
with  general  anesthesia  and  to  displace  it  in  certain  cases  from  its 
firmly  entrenched  position. 

SOLUTIONS  AND  THEIR  METHODS  OF  USE 

The  following  quotations  are  from  the  report  of  Prof.  Matas  on 
"Local  and  Regional  Anesthesia,"  Louisiana  State  Medical  Society, 
April,  1900: 

"To  the  student  of  American  surgical  history  it  will  be  a  source 
of  pleasure  to  recall  the  fact  that  probably  the  first  clinical  demon- 
stration of  the  value  of  cocain,  when  used  by  the  subcutaneous 
method  for  purposes  of  surgical  anesthesia,  was  made  by  American 
investigators.  Beginning  with  the  earlier  experiences  of  Hepburn 
(November  15,  1884),  of  Hall  and  Halsted  (December  6,  1884),  and 
of  J.  Leonard  Corning  (1885-86),  it  is  gratifying  to  note  that  the 
essential  and  fundamental  principles  upon  which  rests  the  most  ef- 
fective technic  in  cocain  anesthesia  had  been  foreshadowed,  and  in 
some  particulars  completely  elaborated,  by  these  early  pioneer  efforts 
of  American  surgeons." 

Before  attempting  a  further  discussion  of  the  subject,  it  will  be 
well  to  present  a  brief  statement  of  the  discoveries  which  have  exer- 
cised the  most  potent  influence  in  widening  and  perfecting  the 
methods  of  local  and  regional  anesthesia. 

1.  "The  discovery  that  anesthesia  of  the  skin  or  derm  proper  by 
intradermal  infiltration  with  cocain  or  similar  analgesic  agents,  as 
distinguished  from  the  hypodermal  method,  is  the  key  to  success  in 
local  anesthesia,  i.e.,  the  anesthesia  of  the  field  of  operation.     This 
fundamental  fact  seems  to  have  suggested  itself  at  the  same  time 
to  several  observers,  but  the  names  of  W.  S.  Halsted  (1884),  J.  L. 
Corning  (1885),  Reclus  and  Ich  Wall  (1886),  and  Schleich  (1890)  are 
the  first  and  most  prominent  that  occur  in  the  literature  on  the  sub- 
ject, though  Halsted  was  the  first  to  insist  upon  the  importance  of 
the  intradermal  method  and  to  demonstrate  by  a  large  clinical  expe- 
rience its  great  practical  importance." 

2.  "The  discovery  that  the  tissues  are  sensitive  to  the  anesthetic 
action  of  extremely  dilute  solutions  of  cocain  and  other  analgesics 


PRINCIPLES    OF   TECHNIC  159 

(i:  20,000  parts,  Schleich,  Heinze),  and  that  these  can  be  used  effect- 
ively in  exceedingly  weak  and  positively  non-toxic  doses. 

"Corning  showed  the  effectiveness  of  solutions  (warm)  of  %  of  i 
per  cent,  cocain  in  1885.  Reclus  rendered  great  service  by  his  for- 
cible and  constant  pleading  in  favor  of  solutions  not  stronger  than 
i  per  cent.,  which  he  used  as  early  as  1885;  but  to  Schleich  belongs 
the  great  credit  of  reducing  the  strength  of  the  surgical  solutions  to 
MJ  Ho 5  and  /l oo  °f  I  Per  cent.  His  experiments  began  in  1888,  but 
their  value  was  not  fully  recognized  until  the  publication  of  his  great 
work,  'Schmerzlose  Operationen/  in  1896." 

3.  ''The  discovery  by  Schleich  (1888)  that  the  thorough  edemati- 
zation  of  the  tissues  with  standard  iso tonic  solutions  of  sodium  chlorid 
(0.2  per  cent.,  Schleich;  0.8  per  cent.,  Heinze)  at  a  low  temperature 
is  in  itself,  as  a  process,  an  anesthetic  agent.     The  experimental  evi- 
dence on  this  point  began  with  the  observations  of  Potain  (1869), 
Dieulafoy  (1870),  Lebroue  (1870),  and  with  Liebreich's  researches 
on  the  anesthetic  properties  of  pure  water.     Halsted  independently 
called  attention  to  the  same  property  of  distilled  water  when  infil- 
trated into  the  derm,  and  also  called  attention  to  the  efficacy  of  very 
dilute  solutions  of  cocain  as  early  as  1884.     While  saline  infiltration 
is  not  to  be  ranked  as  a  surgically  practical  anesthetic,  it  is  a  most 
powerful  adjuvant  to  local  anesthesia  by  increasing  the  effectiveness 
of  extremely  dilute  solutions  of  cocain  in  many  ways  that  will  be 
referred  to  later. 

4.  "The  very  important  discovery  made  by  Dr.  J.  Leonard  Corn- 
ing, of  New  York  (1885),  that  the  action  of  cocain  can  be  indefinitely 
prolonged  as  long  as  the  circulation  of  the  anesthetized  area  is  ar- 
rested by  elastic  constriction  or  other  mechanical  devices.     This  is 
Coming's  great  discovery,  undoubtedly  the  most  important  of  his 
many  original  suggestions,  unless  it  be  his  discovery  of  the  spinal  sub- 
arachnoid  method  of  cocainization,  in  which  his  name  will  always  be 
coupled  with  that  of  Bier.     The  value  of  circulation  stasis  in  pro- 
longing and  intensifying  the  effect  of  cocainization  occurred  sepa- 
rately to  Mayo  Robson,  of  Leeds,  in  1886,  Chandelux,  of  Lyons,  1885, 
and  to  Kummer,  of  Geneva,  1889,  but  it  is  Corning  who  first  sug- 
gested and  popularized  it  by  his  numerous  practical  demonstrations 
and  contributions  on  the  subject." 

5.  "The  discovery  that  the  infiltration  of  the  sectional  area  of  a 
nerve-trunk  in  any  part  of  its  course  with  cocain  or  similar  analgesics 
is  followed  by  a  sensory  paralysis  of  its  entire  peripheral  distribution, 
thus  causing  a  complete  anesthesia  of  all  the  parts  that  it  supplies. 


160  LOCAL   ANESTHESIA 

The  infiltration  of  the  nerves  in  this  manner  immediately  'blocks' 
the  way  to  all  afferent  or  sensorial  impressions  up  to  the  point  where 
the  injection  or  'blockade'  exists.  This  procedure  is  equivalent  to 
a  complete  section  of  all  the  centripetal  fibers  of  the  nerve,  only  that 
the  effects  are  transitory  as  long  as  the  circulation  is  not  controlled. 
This  discovery,  which  is  now  recognized  as  a  law  in  cocain  technic, 
is  the  foundation  of  the  regional,  as  distinguished  from  the  purely 
local,  methods  of  anesthesia.  The  first  demonstration  of  its  surgical 
value  we  owe  to  Hall  and  Halsted's  clinical  experiments  in  1884, 
undertaken  almost  immediately  after  Koller's  announcement.  It 
was  also  demonstrated  by  Barrenechea,  of  Santiago,  Chili,  1885;  and 
to  some  extent  recognized,  but  not  utilized,  as  we  now  understand  it, 
by  J.  Leonard  Corning  in  1885.  It  was  more  fully  established  as  a 
physiologic  fact  by  U.  Mosso  (1886)  and  by  Francois  Franck  (1892). 

"In  German  clinics  it  was  probably  first  practised  by  Kochs  in 
1886,  who  was  inspired  by  the  researches  of  Mosso  (1886)  and  Fein- 
berg  (1885),  but  it  was  popularized  by  Oberst,  of  Halle  (1886),  and 
his  pupils,  who  still  refer  to  it  as  'Oberst's'  method,  and  by  Braun,  of 
Leipsic,  a  little  later.  Up  to  1897  the  principle  was  utilized  only  in 
an  indirect  manner,  i.e.,  by  paraneural  subcutaneous  injections  and 
in  small  operations.  The  application  of  this  principle  by  direct  in- 
jection into  the  nerves  exposed  by  dissection  was  first  made  system- 
atically by  Dr.  George  W.  Crile,  of  Cleveland,  Ohio,  who  amputated 
a  leg  painlessly  after  injecting  the  sciatic  and  anterior  crural  nerves 
on  May  18,  1897,  and  by  myself  (Matas),  independently  (January, 
1898),  in  amputating  the  hand,  after  a  preliminary  cocainization  of 
the  ulnar,  median,  and  musculospiral  nerves  at  the  bend  of  the  elbow. 
The  same  principle  was  most  admirably  utilized  by  Dr.  Gushing  and 
others  in  Dr.  Halsted's  clinic  (Johns  Hopkins  Hospital)  about  the 
same  time  (1907)  for  the  radical  cure  of  inguinal  hernia.  Dr.  Young, 
of  the  same  institution,  had  also  previously  utilized  this  method  in 
securing  anesthesia  of  the  thigh  for  Thiersch  grafting,  which  he  did 
by  injecting  the  external  cutaneous  nerve  under  Poupart's  ligament." 

6.  "The  greater  appreciation  in  recent  years  of  the  physiologic 
fact  that  all  the  tissues  and  organs  of  the  body,  with  the  notable 
exception  of  the  papillary  layer  of  the  skin  and  the  nerves,  are,  in 
normal  conditions,  practically  devoid  of  sensibility,  and  that  if  the 
sensation  of  the  derm  and  of  the  nerves  that  supply  a  given  region 
is  subdued  by  an  artificial  anesthetic,  the  sensibility  of  the  tissues  can 
be  practically  disregarded  from  the  operative  point  of  view.  On 
the  other  hand,  the  importance  of  psychic  pain  in  the  course  of  op- 


PRINCIPLES    OF   TECHNIC  l6l 

erations  is  not  to  be  underestimated;  and,  as  this  cannot  be  con- 
trolled by  purely  local  anesthetic  agents,  it  remains  a  serious  obstacle, 
which  in  major  surgery  frequently  compels  a  recourse  to  general  or 
cerebral  anesthetics  in  spite  of  the  total  abolition  of  sensation  in  the 
field  of  operation.  The  evidence  on  this  point  can  be  traced  to 
numerous  and  even  ancient  sources,  but  its  great  significance  in  the 
practice  of  local  anesthesia  has  been  most  forcibly  presented  by  Dr. 
O.  Bloch,  of  Copenhagen.  (See  'Bibliotek  forLaeger,'  Copenhagen, 
1898;  'Revue  de  Chir.,'  Paris,  January  10,  1900;  also  H.  Lilienthal, 
'Anp.  of  Surg./  1898,  vol.  xxvii.) 

"As  a  result  of  the  practical  applications  of  the  principles  em- 
bodied in  these  discoveries  or  generalizations,  the  technic  of  local  and 
regional  anesthesia  has  been  gradually  evolved  into  a  method,  or  a 
variety  of  methods,  which  for  efficiency  and  safety  far  outstrip  the 
most  sanguine  expectations  of  the  early  advocates  of  local  anesthesia. 
Not  only  all  the  exigencies  of  minor  surgery  are  met  with  success  by 
the  new  methods,  but  they  are  applicable  with  still  greater  force  in 
a  constantly  increasing  number  of  grave,  critical,  and  major  condi- 
tions which,  a  few  years  ago,  would  have  been  regarded  as  absolutely 
impracticable  without  the  aid  of  general  anesthetics. 

"Before  proceeding  to  consider  the  field  of  application  of  the  new 
technic,  and  the  advantages  that  can  be  gained  by  its  more  frequent 
and  systematic  application  in  general  surgical  practice,  let  us  first 
define  and  classify  these  methods  in  order  that  their  indications  and 
limitations  may  be  the  better  understood." 

CLASSIFICATION  OF  THE  METHODS  OF  LOCAL  AND  REGIONAL 
ANESTHESIA  IN  WHICH  COCAIN  AND  THE  OTHER  ALLIED 
ANALGESIC  DRUGS  ARE  UTILIZED  AS  THE  ACTIVE  AGENTS 

"It  should  be  first  clearly  understood  that  the  artificial  anesthesia 
of  any  given  tissue  or  organ  of  the  body  is  entirely  dependent  for  its 
production  upon  the  suppression  of  all  sensorial  (irritant)  impressions 
made  upon  that  region  through  the  agency  of  the  nervous  system. 
This  suppression  can  be  effected  by:  (i)  Paralyzing  the  peripheral 
nerve-endings  or  terminal  organs  of  sensation,  as  in  the  papillary 
layer  of  the  skin;  or  (2)  by  'blocking'  or  obstructing  the  path  of  all 
sensorial  impressions  in  the  nerve-trunks,  including  the  sensory  roots 
in  the  spinal  cord  that  connect  the  field  of  operation  with  the  sen- 
sorium." 

Before  considering  the  different  methods  of  local  anesthesia,  we 
must  bear  in  mind  that  it  is  an  operative  analgesia  that  is  aimed  at, 


1 62  LOCAL   ANESTHESIA 

and  not  an  anesthesia  in  the  true  meaning  of  this  term ;  it  is  a  paraly- 
sis of  the  pain-conducting  fibers,  and  not  those  which  conduct  purely 
tactile  sensations,  consequently  the  patient  is  always  able  to  feel  the 
contact  of  instruments,  fingers,  etc.,  in  the  operative  area,  but  pain 
is  absent.  True  anesthesia  can  be  secured,  but  it  is  necessary  to  use 
much  stronger  solutions,  as  the  tactile  conducting  nerve-fibers  are 
much  more  resistant  to  the  influence  of  the  weaker  solutions;  for  this 
purpose  it  is  accordingly  often  necessary  to  use  solutions  of  from  i  to 
2  per  cent,  strength,  which  are  clearly  unnecessary  for  surgical  pur- 
poses where  a  perfect  analgesia  can  be  secured  by  solutions  of  from 
0.25  per  cent,  and  often  weaker. 

"Schleich,  who  is  the  father  of  the  infiltration  method,  was  first 
to  call  attention  to  the  value  of  salt  in  preventing  the  pain  produced 
by  plain  water  infiltration,  and,  while  many  of  his  conclusions  have 
been  more  or  less  contradicted  by  the  experimental  studies  of 
Custer,  Heinze,  and  Braun,  the  fact  remains  that  his  first  appreciation 
of  the  remarkable  sensitiveness  of  the  tissues  to  such  weak  dilution  of 
cocain  as  i  :  20,000  revolutionized  the  technic  of  local  anesthesia  and 
gave  new  impetus  to  this  mode  of  practice.  According  to  Schleich, 
the  edematization  of  the  tissues  with  a  salt  solution  (0.2  per  cent.)  at 
a  lower  temperature  than  the  body  heat  is  the  essential  condition 
required  for  the  production  of  local  anesthesia.  The  small  quantity 
of  the  analgesic  drug  that  he  adds  to  his  solutions  (%,  ^{Q,  J^oo  °f  I 
per  cent,  cocain)  is  simply  intended,  he  claims,  to  suppress  the  ab- 
normal hyperesthesia  of  pathologic  tissues.  When  dealing  with  nor- 
mal tissues  he  believes  that  a  plain  0.2  per  cent,  salt  solution  is 
sufficient  to  anesthetize,  provided  the  tissues  are  thoroughly  edema- 
tized.  The  modus  operandi  of  the  simple  infiltration  method,  as  he 
admits,  does  not  depend  solely  upon  the  injection  of  a  hypotonic  salt 
solution;  there  are  other  factors  which  enter  more  powerfully  into  the 
causation  of  the  anesthesia.  These  are:  (i)  The  ischemia  of  the 
tissues  and  partial  stasis  caused  by  the  great  pressure  exercised  by 
the  injected  fluid  on  the  capillaries  and  blood-vessels;  (2)  the  com- 
pression of  the  terminal  nerve  elements  themselves  from  the  same 
cause;  (3)  the  lower  temperature  of  the  infiltrated  area  caused  by 
using  cold  solutions,  or  by  cooling  these  after  their  injection  into  the 
parts.  These  purely  physical  conditions  are  undoubtedly  of  great 
importance  in  favoring  and  intensifying  the  action  of  the  analgesic 
drug,  and  upon  the  thoroughness  with  which  they  are  brought  to 
play  largely  depends  the  success  of  the  infiltration  method  as  it  is 
practised  by  Schleich.  That  Schleich  has  underestimated  the  im- 


PRINCIPLES    OF   TECHNIC  163 

portance  of  the  paralyzing  effects  of  the  cocain  which  enters  into  the 
composition  of  his  solution  cannot  be  doubted.  Heinze  and  Braun 
contend,  as  a  result  of  numerous  experiments,  that  Schleich's  solu- 
tions owe  their  entire  analgesic  effect  to  the  cocain  they  contain,  and 
my  personal  experience  has  convinced  me  that  if  the  cocain  were 
excluded  from  them  they  would  cease  to  be  of  value  as  practical 
surgical  anesthetics.  On  the  other  hand,  we  must  recognize  that 
without  the  process  of  edematization  the  weak  solutions  of  cocain 
which  Schleich  has  taught  us  to  use  so  effectively  would  become 
practically  worthless. 

"From  the  preceding  discussion,  it  is  evident  that  there  are  two 
efficient  factors  concerned  in  the  production  of  infiltration  anesthesia 
which  must  be  clearly  differentiated  from  one  another.  One  is  the 
physical  effect  of  the  infiltration  from  pressure,  differences  of  tem- 
perature, etc.  (Schleich) ;  the  other  is  the  chemical  action  of  the  drug 
employed  (cocain,  etc.)  to  paralyze  the  sensitive  structures.  Ac- 
cording to  the  preponderance  of  the  physical  or  the  chemical  factors 
we  may  classify  the  practice  of  local  anesthesia  by  infiltration  into 
two  distinct  methods:  (i)  Schleich's  method,  with  a  very  weak  cocain 
solution,  which  depends  upon  the  infiltration  itself  as  the  effective 
agent  and  lays  the  greatest  possible  stress  upon  its  physical  action; 
and  (2)  the  method  of  Corning,  Reclus,  and  the  earlier  German 
anesthetizers  (Wolfler,  Landerer,  etc.),  in  which  the  tissues  are  in- 
jected, layer  by  layer,  with  stronger  solutions  (i  to  4  per  cent,  cocain), 
and  which  depends  for  its  efficiency  almost  exclusively  upon  the 
diffusion  of  the  chemical  analgesics  dissolved  in  the  solutions. 

"The  preference  given  in  the  selection  of  these  methods  will  be 
determined  by  certain  conditions,  which  will  be  referred  to  in  dealing 
with  the  topographic  application  of  the  technic  in  the  various  regions 
of  the  body.  In  a  general  way,  Schleich's  method  of  infiltration  is 
indicated  in  all  operations  in  which  the  circulation  cannot  be  con- 
trolled and  in  which  the  major  part  of  the  infiltrating  solution  must 
be  allowed  to  remain  in  the  tissues.  In  this,  as  in  all  other  methods 
of  local  anesthesia,  it  is  most  important  to  remember  that  the  derm 
proper,  and  especially  its  papillary  layer,  must  be  first  edematized 
by  intracuticular  infiltration  before  beginning  the  infiltration  of  the 
deeper  planes;  the  same  rule  applies  to  the  mucous  surfaces.  This 
is  a  sine  qua  non  in  local  anesthesia  which  cannot  be  repeated  too 
often." 

The  original  solutions,  as  advocated  by  Schleich,  are  the  following: 


164  LOCAL   ANESTHESIA 

No.  i  No.  2  No.  3 

Cocain  mur 0.2  Cocain  mur o .  i  Cocain  mur o .  01 

NaCl 0.2  Nad 0.2  Nad 0.2 

Morphin  sulph. .  .  .  0.02  Morphin  sulph . . .  .  0.02  Morphin  sulph .  .       0.005 

Aquae  destil 100.0  Aquae  destil 100.0  Aquas  destil 100. o 

Solution  No.  i  was  intended  for  the  skin,  sensitive  and  inflamed 
tissues. 

Solution  No.  2,  for  less  sensitive  tissues,  such  as  the  subcutaneous 
planes. 

Solution  No.  3,  for  massive  infiltration  of  the  deeper  tissues,  which 
possess  very  little  sensibility. 

The  idea  in  the  addition  of  morphin  was  that  it  exercised  some 
slight  local  anesthetic  influence  and  exerted  its  constitutional  effect 
by  the  time  the  anesthesia  was  passing  off,  thus  relieving  the  after- 
pain  in  the  wound.  The  idea  of  depending  upon  the  anesthetic  in- 
fluence of  such  weak  solutions  of  NaCl  is  objectionable,  as  mentioned 
elsewhere  in  this  book,  and  the  addition  of  morphin  to  the  anesthetic 
solutions  for  its  constitutional  effect  is  inadvisable;  our  aim  should 
be  rather  to  simplify  the  solution,  and  when  morphin  is  to  be  used  to 
give  a  definite  dose  some  time  before  operation,  as  we  advocate  in  the 
combination  of  morphin  and  scopolamin.  . 

Recently,  Schleich  has  modified  the  formula  of  his  solutions  to 
the  extent  of  reducing  the  quantity  of  cocain  in  each  one-half  and 
adding  an  equal  quantity  of  alypin,  otherwise  the  solutions  are  the 
same  as  originally  advocated. 

The  admixture  of  different  anesthetic  salts  in  solution  should, 
according  to  Burgi's  views  (discussed  in  the  chapter  on  Scopolamin- 
morphin  Injections),  exert  a  more  decided  influence  than  when  a 
total  equivalent  quantity  of  any  one  agent  is  used ;  thus  retaining  the 
good  points  of  each,  while  being  sufficiently  weak  in  each  constituent 
to  prevent  any  unpleasant  results  that  may  arise  from  the  use  in  too 
large  quantities  of  that  particular  constituent.  This  fact  has  re- 
cently been  made  use  of  by  Schleich  in  combining  alypin  with  cocain 
in  his  solutions.  The  advantages  in  the  use  of  novocain  are  so  great 
and  its  toxicity  so  low,  permitting  so  much  more  of  it  to  be  used,  and 
the  clinical  results  so  entirely  satisfactory  that  we  have  not  found  it 
necessary  to  resort  to  any  combinations,  but,  if  such  were  done, 
novocain  would  be  used  as  one  of  the  constituents. 

Schleich  is  opposed  to  the  use  of  adrenalin  for  general  use,  but 
approved  of  it  for  the  extraction  of  teeth  and  on  mucous  surfaces. 

The  views  of  Braun,  Heinze,  and  other  prominent  advocates  of 


PRINCIPLES    OF   TECHNIC  165 

local  anesthesia  are  opposed  to  those  of  Schleich  in  the  use  of  solutions 
of  such  low  freezing-point,  heterotonic  solutions,  claiming  that  solu- 
tions of  such  low  specific  gravity  injure  the  tissues;  preferring  to 
depend  exclusively  upon  the  chemical  influence  of  the  solution  rather 
than  upon  any  physical  influence  for  their  anesthesia,  and  conse- 
quently utilize  only  normal  salt  solutions  as  their  solvent  medium. 
On  theoretic  and  physiologic  grounds  this  would  seem  to  be  correct 
(see  chapter  on  Osmosis),  but  from  a  very  extensive  personal  clinical 
experience,  extending  over  many  years,  and  the  accumulation  of 
thousands  of  cases  throughout  the  surgical  world,  it  would  appear 
that  these  fears  have  not  been  borne  out  on  clinical  grounds.  Our 
own  reasons,  for  discarding  the  use  of  the  Schleich  solutions,  have 
been  owing  to  the  many  advantages  presented  by  the  use  of  some  of 
the  newer  anesthetics,  notably  novocain,  which  we  will  discuss  later. 
Following  the  introduction  of  eucain,  Braun  advocated  the  follow- 
ing solution : 

Eucain  B 0.2 

Nad 0.8 

Aquas  destil 100.0 

to  which  adrenalin  was  added.     This  was  a  very  serviceable  solution, 
and  is  discussed  under  Eucain. 

Later  Braun  suggested  the  following  solutions,  which  are  those 
recommended  in  his  book  on  "Local  Anesthesia": 

Solution  No.  i 
Cocain  hydrochlorate o.  i 

or  Novocain 0.25 

Normal  salt  solution 100 .  o 

Adrenalin  solution (i :  1000) 

or  Homorenon  solution  (4  per  cent.) 5  drops 

Solution  No.  2 
Cocain  hydrochlorate o .  i 

or  Novocain 0.25 

Normal  salt  solution 50 .  o 

Adrenalin  solution (i :  1000) 

or  Homorenon  solution  (4  per  cent.) -.       5  drops 

Solution  No.  2  diluted  one-half  with  normal  salt  solution  gives 

solution  No.  i. 

Solution  No.  3 

Cocain  hydrochlorate o .  05 

or  Novocain o .  i 

Normal  salt  solution 10 .  o 

Adrenalin  solution (i:  1000) 

or  Homorenon  solution  (4  per  cent.) 5  drops 


1 66  LOCAL  ANESTHESIA 

Solution  No.  4 

Cocain  hydrochlorate o .  05 

or  Novocain o .  i 

Normal  salt  solution 5.0 

Adrenalin  solution (i :  1000) 

or  Homorenon  solution  (4  per  cent.) 5  drops 

Solution  No.  4  diluted  one-half  with  normal  salt  solution  gives 
solution  No.  3. 

Solution  No.  i  is  the  one  recommended  for  general  use,  while  in 
more  sensitive  or  inflamed  tissues  solution  No.  2  may  be  used.  Solu- 
tions No.  3  and  No.  4  are  intended  for  such  purposes  as  nerve-block- 
ing, or  for  use  in  highly  inflamed  or  sensitive  tissues,  and  for  use  in 
special  regions  (nose,  throat,  teeth,  etc.). 

The  above  solutions  serve  an  extensive  range  of  usefulness,  and 
are  found  equal  to  the  demands  of  any  condition  except  the  purely 
topical  applications,  as  used  in  the  eye,  nose,  and  throat,  and  for  such 
special  work. 

In  selecting  solutions  for  practical  clinical  purposes  we  have  tried 
to  simplify  to  the  minimum  the  number  of  solutions  used,  and  have 
found  it  advisable  to  reduce  the  content  of  sodium  chlorid  as  advo- 
cated in  the  Braun  solutions.  In  this  respect  we  have  adopted  a 
medium  between  that  recommended  by  Schleich  and  the  Braun  for- 
mula; securing  a  certain  degree  of  purely  physical  action  from  the 
infiltration,  at  the  same  time  having  the  content  of  sodium  chlorid 
sufficiently  high  to  prevent  any  possible  objection  being  found  to  it 
on  purely  physiologic  grounds.  At  the  same  time  we  have  tried  to 
forestall  the  possibility,  however  remote,  of  any  injury  resulting  in 
highly  sensitive  tissues  as  the  result  of  too  pronounced  imbibition  by 
the  tissue-cells.  Consequently,  after  an  extensive  trial  in  several 
hundred  major  operations  we  suggest  the  following  as  used  by  us: 

Solution  No.  i 

Novocain o.  25  (^  per  cent.) 

Normal  salt  solution  (one-half) 100.0  (0.45  per  cent.  NaCl) 

The  above  solution  is  the  one  recommended  for  general  use,  and 
in  the  great  majority  of  cases  will  be  found  amply  sufficient  for  all 
purposes.  It  has  been  utilized  by  us  for  the  performance  of  major 
operations  about  the  body  generally,  as  well  as  in  such  highly  sensi- 
tive regions  as  the  face  and  anus ;  it  is  amply  sufficient  for  the  skin, 
and,  owing  to  the  mild  toxicity  of  the  novocain,  can  be  used  for 
massive  infiltration  of  the  deeper  parts  as  well;  it  is  found  equally 
effective  for  the  blocking  of  medium-sized  nerves,  even  as  large  as 


PRINCIPLES    OF    TECHNIC  167 

those  of  the  brachial  plexus,  and  can  be  used  on  the  sciatic,  but  for 
the  latter,  as  well  as  occasionally  for  the  former,  Solution  No.  2  may 
be  found  more  desirable. 

Solution  No.  2 

This  solution  is  intended  for  use  in  more  sensitive  parts,  such  as 
the  nose,  throat,  mouth  (teeth),  for  intraneural  injections  (brachial 
plexus,  sciatic),  and  for  paraneural  injections,  about  the  branches  of 
the  trigeminus,  pudic,  etc.,  when  reaching  these  nerves  in  their  deep 
positions  with  long  needles.  The  solution  can  be  made  in  0.5  to  2 
per  cent,  strength,  according  to  the  apparent  needs  of  the  particular 
case,  and  is  as  follows: 

Novocain 0.5,  i  or  2  (%  to  2  per  cent.) 

Normal  salt  solution  (one-half) 100.0  (0.45  per  cent.  Nad) 

This  solution  will,  however,  be  found  rarely  needed,  except  in 
special  fields  of  work,  as  above  mentioned. 

The  advantages  of  novocain,  and  the  reasons  for  discarding  the 
Schleich  solutions  which  we  had  so  long  used,  is  the  lessened  toxicity 
of  novocain  (one-fifth  to  one- seventh  that  of  cocain),  its  perfect 
toleration  by  the  tissues,  and  its  ability  to  stand  thorough  steriliza- 
tion by  heating,  as  it  can  be  repeatedly  boiled  without  suffering  de- 
terioration ;  these  and  other  advantages  mentioned  in  the  discussion  of 
novocain  place  it,  for  the  present  at  least,  at  the  highest  pinnacle  of 
success  of  the  synthetic  chemist's  art. 

The  probability  of  the  discovery  of  an  anesthetic  agent  absolutely 
devoid  of  toxicity  or  irritating  qualities  seems  very  unlikely;  how- 
ever, later  advances  may  be  able  to  still  further  reduce  the  toxicity. 

In  the  preparation  of  solutions  for  purely  topical  applications, 
5,  10,  20  per  cent,  and  stronger,  it  is  inadvisable  to  add  sodium  chlorid; 
the  concentration  of  these  solutions  places  their  freezing-point  con- 
siderably above  that  of  blood-serum  (they  are  hypertonic). 

Regarding  the  addition  of  adrenalin  considerable  care  should  be 
exercised,  as  this  is  an  agent  not  free  from  danger  itself,  and  many 
unpleasant  symptoms  arising  during  the  course  of  an  operation  at- 
tributed to  the  anesthetic  agent  are  in  reality  due  to  the  adrenalin. 
It  is  well  to  estimate  the  total  quantity  of  solution  likely  to  be  needed 
for  an  operation,  allowing  slightly  an  excess,  and  to  this  total  quan- 
tity, which  has  been  previously  sterilized,  add  the  adrenalin  from  a 
sterile  bottle  and  with  a  sterile  dropper,  using  not  over  10  drops  to 
a  3-ounce  mixture,  or  20  drops  to  a  4-  or  6-ounce  mixture,  which  will 


1 68  LOCAL   ANESTHESIA 

be  found  amply  sufficient  for  all  ordinary  uses;  by  confining  one's 
self  within  these  limits  of  safety  no  unpleasant  symptoms  will  arise. 
Additional  precautions  may  be  necessary  in  using  adrenalin  upon 
those  with  very  high  blood-pressure  and  in  patients  suffering  from 
Graves'  disease,  where  the  vascular  system  is  very  easily  excited. 
Aside  from  the  unpleasant  constitutional  effects  which  adrenalin  may 
exercise  at  the  time  of  its  use,  when  used  too  strong,  it  is  likely  to  be 
followed  by  pain  in  the  wound,  and  its  injudicious  use  in  strong  solu- 
tion has  been  followed  by  gangrene. 

It  will  often  be  found  convenient  for  office  use,  and  for  those  doing 
a  limited  amount  of  surgery  to  procure  the  novocain  in  tablet  form 
of  definite  strength,  with  or  without  sodium  chlorid  and  always 
without  adrenalin,  these  tablets  are  then  added  to  the  necessary 
amount  of  water  and  the  whole  sterilized,  when  the  adrenalin  is  then 
added. 

The  disadvantage  in  the  tablets  already  containing  adrenalin  is 
that  its  keeping  quality  in  this  condition  is  very  questionable  unless 
quite  fresh;  and  more  particularly  as  in  the  sterilizing  process  the 
adrenalin  is  largely  destroyed. 

The  idea  of  adding  other  agents,  antiseptics,  etc.,  to  the  solutions 
is  to  be  avoided,  as  these  substances  often  exert  a  hemolytic  influence 
or  otherwise  prove  irritant  to  the  tissues;  the  possible  contamination 
of  the  solutions  by  alkalis  (so  often  used  in  the  sterilization  of  in- 
struments) is"  particularly  to  be  avoided,  being  both  destructive  to 
the  anesthetic  agent  and  when  sufficiently  strong  exerting  decided 
hemolytic  influence.  Notwithstanding  this  knowledge,  Bignon  at 
one  time  claimed  that  cocain  in  alkaline  solution  was  more  effective 
than  in  other  media,  alkalinizing  the  solution  with  sodium  carbonate, 
making  a  milky-like  mixture.  Braun  tested  the  efficiency  of  such 
solutions,  and  found  them  inferior  in  duration,  intensity,  and  diffu- 
sion power  to  the  ordinary  method  of  preparation,  which  gives  a 
solution  nearly  neutral  in  reaction. 

More  recently  3  per  cent,  solutions  of  sodium  phosphate  have  been 
recommended  for  use  with  novocain  as  a  substitute  for  the  sodium 
chlorid  usually  employed;  it  was  claimed  for  this  combination  that  it 
produced  a  more  profound  and  prolonged  anesthesia.  After  a  rather 
extended  trial  in  our  clinics  we  failed  to  note  any  advantages,  and 
have  accordingly  returned  to  NaCl.  It  may  be  said,  however,  that 
the  combination  is  well  tolerated  by  the  tissues  as  no  unfavorable 
reaction  was  noted,  and  the  anesthesia,  while  good,  had  nothing  to 
commend  it  over  the  sodium  chlorid  solution. 


PRINCIPLES    OF   TECHNIC  1 69 

The  addition  of  other  agents  to  the  anesthetic  solution  has  more 
recently  been  advocated,  potassium  sulphate  0.25  to  i  per  cent,  or 
calcium  chlorid  0.25  to  0.5  per  cent.,  the  claim  has  been  made  that 
both  of  these  agents  intensify  and  prolong  the  anesthetic  effect. 

After  a  rather  limited  trial  I  failed  to  note  any  advantage 
and  accordingly  discontinued  them,  but  it  is  possible  that  from  a 
more  extended  use  the  benefits  claimed  may  have  become  more 
apparent. 

The  use  of  highly  concentrated  solution  of  cocain  is  so  general 
with  surgeon  specialists,  particularly  in  the  nose  and  throat,  that  a 
few  remarks  regarding  the  action  of  such  solution  may  not  prove  out 
of  place  here,  and  should  be  considered  in  connection  with  informa- 
tion given  in  the  chapter  on  Osmosis. 

The  employment  of  such  strong  solutions  as  are  sometimes  used 
is  only  possible  in  such  highly  vascular  (high  nutrition)  tissues  as  in 
the  nose  and  throat  and  in  superficial  wounds,  which  heal  largely  by 
granulation  and  can  be  kept  freely  irrigated;  if  used  elsewhere,  the 
hydroscopic  action  of  these  solutions  would  so  desiccate  the  tissue- 
cells  as  to  be  likely  to  produce  serious  consequences  (the  injection 
into  the  skin  of  a  10  per  cent,  solution  of  cocain  is  painful  and  leaves 
behind  an  inflamed  indurated  area). 

The  views  of  the  specialist  on  this  point  are  so  ably  put  forth  by 
Dr.  John  Leshure  ("New  York  Med.  Jour."  of  February  6,  1909) 
that  I  quote  his  arguments  at  length: 

"The  marked  absorptive  power  possessed  by  mucous  membranes 
renders  them  peculiarly  susceptible  to  the  action  of  drugs  applied 
directly  to  their  surface. 

"  In  the  case  of  cocain  used  for  the  purpose  of  inducing  local  anes- 
thesia a  certain  amount  of  absorption  is  desirable,  that  is,  it  is  neces- 
sary that  the  drug  should  reach  the  level  of  the  nerve-endings,  but 
it  is  undesirable  that  it  should  enter  the  large  venous  and  lymphatic 
radicles,  which  are  placed  at  a  deeper  level,  since,  by  way  of  these 
vessels,  general  absorption  takes  place,  and  toxic  symptoms  of  greater 
or  lesser  degree  are  likely  to  occur. 

"Both  cocain  and  adrenalin  have  the  power  of  contracting  super- 
ficial and  deep  vessels,  but  the  degree  and  rapidity  of  this  contraction 
appears  to  be  proportionate  to  the  strength  of  drug  solution  used. 

"This  is  particularly  true  of  the  deep  vessels,  and  it  is  necessary 
to  apply  strong  solution  of  cocain  and  adrenalin  to  contract  these 
deeper  structures  promptly,  for  the  solutions  are  rapidly  diluted  by 
the  copious  mucous  secretions  and  osmosis  through  the  vessel  walls 


1 70  LOCAL  ANESTHESIA 

can  then  take  place  readily.  We  wish  to  bring  the  drug  to  the  vessel 
wall,  but  not  through  it,  and  to  influence  the  vasomotor  fibers  which 
surround  the  vessel. 

"Fluids  of  high  density,  such  as  the  cocain  solution  to  be  men- 
tioned, are  not  readily  taken  up  by  the  blood-vessels,  and  by  the  time 
they  are  sufficiently  diluted  to  be  so  taken  up  the  local  circulation  has 
been  blocked  off  by  the  drug. 

"By  a  strong  cocain-adrenalin  solution  is  meant  one  made  by  dis- 
solving i  gram  of  cocain  hydrochlorid  (flaky  crystals)  in  i  c.c.  of  a 
i :  1000  solution  of  adrenalin  chlorid.  This  solution  contains  about 
55  per  cent,  of  cocain  by  volume,  and  has  a  specific  gravity  of  i.no. 

"The  following  table  gives  the  specific  gravity  of  some  commonly 
used  solutions  of  cocain: 

2  per  cent =  sp.  gr.  i .  004 

4  per  cent =  sp.  gr.  i .  008 

10  per  cent =  sp.  gr.  i  .020 

20  per  cent =  sp.gr.  i .  040 

25  per  cent =  sp.  gr.  i  .050 

55  per  cent =  sp.  gr.  i.no 

"  Certain  laws  governing  the  absorption  of  aqueous  drug  solutions 
are:  (i)  A  fluid  passes  through  a  membrane  with  a  rapidity  inversely 
proportional  to  the  density  of  the  fluid.  (2)  The  rate  of  absorption 
varies  directly  with  the  fulness  and  density  of  the  blood-vessels  and 
lymphatics.  (3)  The  slower  the  movement  of  the  blood  and  lymph- 
streams  the  slower  will  be  the  rate  of  absorption  of  the  fluid. 

"These  well-recognized  laws  of  physiology  explain  the  local  re- 
tention in  the  tissues  of  the  strong  cocain-adrenalin  solution  and  the 
lasting  anesthesia  and  ischemia  following  its  use. 

"As  the  specific  gravity  of  blood-serum  is  from  1.025  to  1.032, 
reference  to  law  (i)  shows  that  other  things  being  equal  the  strong 
cocain  solution,  having  a  specific  gravity  of  i.no,  will  pass  through 
the  mucous  membrane  of  the  nose  slowly  as  compared  with  the 
weaker  solutions  (4  to  20  per  cent.). 

"The  sequence  of  events  resulting  from  the  application  of  the 
strong  cocain-adrenalin  solution  to  the  mucous  membrane  of  the 
nose  seems  to  be  as  follows: 

"A  prompt,  powerful  stimulus  is  transmitted  to  the  vasoconstric- 
tor fibers  surrounding  the  more  deeply  placed  arterioles.  The  latter 
then  strongly  contract,  slowing  the  local  blood-stream.  At  the  same 
time  the  caliber  of  the  venous  and  lymphatic  radicles  is  narrowed,  and 
the  proximal  pressure  having  been  reduced  venous  stasis  occurs,  as  is 
evidenced  by  the  deep  redness  of  the  membrane. 


PRINCIPLES   OF   TECHNIC  171 

"  General  absorption  is  thus  blocked  off,  and,  the  membrane  con- 
tracting, the  nerve-endings  and  nerve-trunks  are  brought  nearer  to 
the  periphery,  and  consequently  more  directly  under  the  influence  of 
the  local  anesthetic. 

"All  this  time  the  cocain  solution  is  becoming  less  dense,  being 
diluted  by  the  mucous  membrane  secretion,  and  a  certain  amount  of 
absorption  is  taking  place  into  the  nerve-trunks  through  the  axis 
cylinder,  since  this  latter  structure  is  non-medullated  near  its  distal 
end. 

"Areas  quite  remote  from  the  point  of  application  often  are  com- 
plained of  by  the  patient  as  being  anesthetic,  e.g.,  the  teeth.  The 
passage  of  the  drug  up  the  axis  cylinder  to  a  ganglion,  distributing 
fibers  to  neighboring  regions,  may  explain  this  phenomenon. 

"It  has  been  recently  demonstrated  that  toxic  substances  may 
reach  the  central  nervous  system  by  way  of  the  axis  cylinder,  also 
that  absorption  may  take  place  at  the  nodes  of  Ranvier,  there  being  a 
defective  insulation  of  the  axis  cylinder  at  these  nodes. 

"In  operating  nerve- trunks  as  well  as  nerve-endings  are  sure  to 
be  wounded,  and  the  former  must  be  rendered  absolutely  anesthetic 
to  insure  the  patient  immunity  from  pain. 

"The  physiologic  action  of  the  strong  cocain-adrenalin  solution 
can  be  practically  demonstrated,  so  far  as  its  effect  upon  the  blood- 
vessels is  concerned,  using  tadpoles  as  the  subjects  of  investigation. 

"When  from  30  to  35  mm.  in  length  these  animals  have  a  thin, 
membranous,  lateral  outgrowth  from  the  caudal  appendage.  This 
is  highly  vascular,  and  each  half  is  supplied  by  branches  from  the 
aorta  and  central  vein  of  the  corresponding  side,  which  pass  down 
the  thick  central  stem.  The  point  of  practical  importance  is  that 
there  is  no  direct  communication  between  the  blood-vessels  of  the 
two  sides. 

"It  is  possible,  therefore,  to  compare  the  results  obtained  by 
simultaneously  applying  drug  solutions  of  different  strength  to 
corresponding  portions  of  the  structure  referred  to,  which  resembles 
in  many  respects  a  mucous  membrane.  The  animal  is  first  curarized 
by  placing  it  in  a  small  dish,  containing  about  15  ounces  of  water,  in 
which  ^5  gr.  of  curarin  sulphate  has  been  dissolved.  In  from  fifteen 
to  twenty  minutes  the  muscular  system  is  paralyzed,  and  the  tadpole 
will  l^e  quietly  upon  the  microscopic  stage.  The  small  vessels  can  be 
satisfactorily  studied  with  a  two-thirds  objective  and  a  i-inch  eye- 
piece. A  mechanical  stage  contributes  greatly  to  the  ease  of  exami- 
nation. A  small  drop  of  the  strong  cocain-adrenalin  solution  (55 


172  LOCAL   ANESTHESIA 

per  cent,  strength)  is  placed  upon  the  membranous  structure  near  the 
tail  of  the  tadpole,  and  a  drop  of  the  same  size  of  a  4  per  cent,  solution 
of  cocain  in  i :  1000  adrenalin  is  placed  at  a  corresponding  point  on 
the  opposite  side  of  the  caudal  appendage.  Slowing  of  the  blood- 
stream and  venous  stasis  occurs  at  a  much  earlier  period  on  the  side 
with  the  first-named  solution  than  on  that  treated  with  the  weaker 
solution.  In  about  twenty  seconds  the  circulation  in  the  smaller 
vessels  has  practically  ceased.  The  tadpole,  being  a  gill  breather  at 
this  stage  of  its  existence,  cannot  be  kept  alive  more  than  five  or  six 
minutes  out  of  water,  but  control  tests  made  with  uncocainized 
animals  showed  that  death  occurred  as  early  in  these  individuals  as 
when  cocain  was  used. 

"The  fact  would  seem  to  prove  that  general  absorption  could 
hardly  have  taken  place,  since  cocain  is  a  powerful  cardiac  paraly- 
zant,  and  would  have  caused  death  promptly  had  it  entered  the  gen- 
eral circulation." 

The  above  from  Leshure  deserves  careful  consideration,  and  ex- 
plains admirably  the  action  of  highly  concentrated  solution  when 
brought  in  contact  with  the  tissues;  such  solutions  are  swabbed  on 
mucous  surfaces,  as  the  nose  and  throat,  and  are  not  intended  to  be 
injected  into  the  tissues.  Strong  solutions  should  never  be  used  when 
it  is  possible  to  accomplish  the  purpose  with  the  weaker  dilutions. 
If  they  must  be  used,  as  seems  necessary  in  nose  and  throat  work, 
then  we  must  have  a  rational  explanation  for  the  action  of  such  solu- 
tions, founded  on  sound  physiologic  grounds  and  amply  borne  out  by 
clinical  experience.  Such  an  explanation,  I  believe,  is  given  above. 

The  safe  use  of  such  strong  solutions  requires  great  skill,  and  is 
acquired  only  after  long  practice  and  experience  and  is  not  to  be 
lightly  undertaken  by  the  novice. 

The  idea  of  using  other  than  watery  solutions  of  the  anesthetics 
(as  in  oils) ,  might  seem  to  have  some  claims  but  has  been  found  upon 
practical  tests  to  be  unsatisfactory  and  possessing  many  disadvan- 
tages. Water  solutions,  which  are  taken  up  by  both  veins  and 
lymphatics,  are  absorbed  comparatively  rapidly,  while  oily  solutions 
are  absorbed  exclusively  by  the  lymphatics,  which  act  much  more 
slowly,  the  oil  globules  choking  the  lymphatics  and  further  delaying 
the  process.  This  prolonged  retention  in  the  tissues  should  intensify 
the  local  effect  of  the  anesthetic,  as  well  as  permitting  it  to  be  almost 
entirely  exhausted  locally,  thus  diminishing  the  likelihood  of  con- 
stitutional effects. 

These  solutions  have  been  tested  by  Braun  and  found  impractical; 


PRINCIPLES    OF   TECHNIC  173 

the  oily  solutions  are  unsatisfactory  to  use,  diffuse  very  poorly,  exert 
a  weaker  anesthetic  influence,  and  frequently  prove  irritating  to  the 
tissue. 

For  the  sterilization  of  cocain  solutions,  where  it  is  desirable  to 
use  this  salt,  the  solution  will  stand  heating  almost  to  the  boiling- 
point,  and  will  not  suffer  any  appreciable  loss  of  strength,  but  re- 
peated heatings  render  the  solution  inert. 

Mikulicz  has  suggested  the  following  method:  He  dissolves  a 
definite  quantity  of  cocain  in  alcohol,  allows  the  alcohol  to  evaporate, 
and  dissolves  the  precipitate  in  sterile  water  or  salt  solution. 

A  solution  of  cocain  should  not  be  kept  for  more  than  a  few  days 
as  it  very  rapidly  deteriorates,  and  should  frequently  be  made  fresh. 

THE  ARMAMENTARIUM 

It  is  not  at  all  necessary  to  have  a  complicated  outfit  for  the 
application  of  the  various  methods  of  local  anesthesia;  all  that  is 
necessary  is  to  have  a  supply  of  suitable  syringes,  preferably  two  or 
more  of  each,  so  should  one  become  defective  or  broken  the  work  is 
not  interrupted.  The  syringe  should  preferably  be  all  glass,  with 
glass  plungers,  and  have  no  washers;  the  needles  should  slip  on  the 
ground  ends;  needles  which  screw  on  and  require  washers  are  objec- 
tionable; the  screwing  on  process  takes  time,  the  washers  frequently 
give  trouble,  leak,  and  are  otherwise  undesirable.  The  simplest 
outfit  compatible  with  efficiency  is  the  best. 

In  selecting  such  syringes  the  best  makes  will  be  found  the  cheap- 
est in  the  end ;  care  should  be  exercised  in  selecting  them  to  be  sure 
that  the  plungers  work  easily  and  do  not  jam;  the  points  which  fit 
the  needles  should  be  tapering  and  not  pointed  too  acutely,  other- 
wise the  needle  will  not  fit  securely  and  may  fly  off  under  pressure 
from  the  syringe;  the  needles  should  be  as  fine  as  compatible  with 
efficiency.  The  idea  of  needles  which  slip  on  and  off  readily  without 
having  to  unscrew  them  is  of  decided  practical  value  as  well  as 
facilitating  the  refinements  of  technic.  It  is  well  in  selecting  syringes 
to  have  the  different  sizes  fit  the  same  needles,  as  this  interchange- 
ability  will  often  be  found  of  great  practical  advantage  (Figs.  4 
and  5). 

1.  The  syringe  is  more  readily  and  quickly  filled  when  the  needle 
is  off.     When  this  process  has  to  be  frequently  repeated  much  time 
is  saved. 

2.  Where  several  syringefuls  are  to  be  deposited  in  the  same 
position  the  needle  is  allowed  to  remain  in  situ  in  the  tissues;  simply 


174 


LOCAL  ANESTHESIA 


slip  off  the  syringe,  which  is  refilled  and  again  attached,  thus  avoid- 
ing the  necessity  of  making  repeated  skin  punctures,  which  is  an  un- 
necessary trauma.  This  method  is  particularly  of  advantage  in 
infiltrating  the  subcutaneous  tissues,  we  will  say,  over  a  hernia;  here 
the  long  needle,  after  one  puncture  in  the  skin,  is  advanced  in  the 


Fig.  4. — This  illustration  is  reduced  to  about  one-third  size:  the  large  syringe  is  the 
plain  ground  glass  of  the  Luer  or  phylocogen  (P.  D.  &  Co.)  type,  10  c.c.  size;  the  small 
syringe  is  of  the  same  type  and  is  the  ordinary  hypodermic  of  25  to  30  m.  capacity 
(P.  D.  &  Co.  Glaseptic).  The  illustrations  are  intended  to  show  the  absence  of  all 
washers  or  threads  upon  syringe  and  needle;  they  both  have  the  same  size  beveled  glass 
tip  to  fit  the  needles  and  each  fits  the  large  or  small  needle  as  occasion  requires. 

subcutaneous  tissues,  and  several  syringefuls  deposited  at  different 
points,  or  diffused  generally  as  may  seem  advisable. 

Two  sizes  of  syringes  are  recommended,  the  small  ordinary  hypo- 
dermic size  and  a  fairly  large  syringe,  which  will  hold  at  least  10  c.c. 
with  long  needles  (about  3  inches) ;  such  syringes  stand  boiling  well 
and  are  otherwise  surgically  satisfactory.  When  through  using  a 


PRINCIPLES    OF   TECHNIC 


syringe  the  plunger  should  always  be  removed,  wiped,  and  kept  out 
of  the  barrel;  if  allowed  to  remain  in  the  barrel,  it  may  become 
jammed  and  only  be  removed  after  much  difficulty. 


Diameter 

Length 25 


Fig.  5. — Assortment  of  needles  (after  Braun). 


For  massive  infiltration,  and  where  the  use  of  large  quantities  of 
solution  are  necessary,  the  Matas  infiltration  apparatus  will  be  found 
highly  serviceable,  as  it  permits  the  easy  infiltration  of  large  areas 
within  a  few  minutes. 


176  LOCAL   ANESTHESIA 

Most  of  the  more  commonly  used  formulas  (Schleich,  Braun,  etc.) 
of  the  various  local  anesthetics  can  be  obtained  on  the  market  in 
convenient  tablet  form,  which  when  dissolved  in  a  stated  quantity 
of  water  will  give  the  desired  solution.  These  tablets  are  usually 
sterilized  and  some  contain  adrenalin ;  this  last  ingredient  is  inadvis- 
able in  tablet  form,  as  its  keeping  qualities  are  very  poor. 

More  recently  manufacturers  have  put  upon  the  market  sterile 
tablets  in  sterile  containers  consisting  of  novocain,  Nad,  and  the 
synthetic  adrenalins  (notably  suprarenin  synthetic).  These  are  the 
best  and  are  in  graded  strength  of  novocain  and  suprarenin,  but  with 
a  uniform  strength  of  NaCl,  so  that  their  solution  in  sterile  water 
yields  standard  solutions. 

The  tablets  are  highly  useful  for  office  use  and  for  the  extempo- 
raneous preparations  of  small  quantities  of  solution.  The  objection 
to  tablets  containing  the  animal  extract  adrenalin  does  not  hold  good 
here,  as  the  synthetic  preparations  have  been  proved  to  possess 
greater  keeping  qualities,  and,  especially  with  suprarenin  synthetic, 
capable  of  a  moderate  amount  of  sterilization  (boiling  for  from  three 
to  five  minutes). 

The  sterilization  of  these  tablets  can  be  depended  upon  when 
obtained  from  reliable  manufacturers,  but  it  is  impossible  to  keep 
them  sterile  when  the  container  is  constantly  being  opened  for  the 
removal  of  tablets.  We  frequently  prefer  for  institution  or  hospital 
work  to  prepare  our  own  solutions  freshly  sterilized,  to  which  we 
add  just  before  use  the  desired  quantity  of  adrenalin  or  suprarenin 
synthetic  as  preferred.  This  method  has  been  found  more  satis- 
factory in  major  operations,  where  it  is  imperative  to  have  an 
absolutely  sterile  and  dependable  solution. 

CLINICAL  APPLICATION 

In  starting  to  anesthetize  any  area  the  first  step  should  be  the 
production  of  intradermal  anesthesia,  and  should  be  done  with  a 
small  syringe  and  fine  needle.  In  highly  sensitive  individuals  the 
point  of  entrance  of  the  needle  may  first  be  anesthetized  with  ethyl 
chlorid,  but  this  is  ordinarily  unnecessary;  if  the  skin  at  the  selected 
point  is  first  pinched  up  between  the  thumb  and  finger  and  held 
firmly  it  lessens  its  sensibility;  with  a  quick  but  light  thrust  the 
needle  is  advanced  beneath  the  epidermis.  While  making  this  ini- 
tial stick  the  thumb  should  be  on  the  plunger,  so  that  at  the  moment 
that  the  needle  enters  .the  skin  the  solution  can  be  injected;  in  this 
way  this  initial  stick  is  often  made  without  the  patient's  knowledge. 


PRINCIPLES    OF    TECHNIC 


177 


This  injection  must  be  intradermal  and  not  subcutaneous;  it 
should  develop  a  distinct  wheal,  which  stands  up  from  the  surround- 
ing surface  like  an  urticarial  wheal  (Fig.  6).  This  anesthetic  point 
should  be  regarded  as  a  "station"  from  which  the  anesthesia  is  dis- 
tributed in  the  desired  direction,  either  continuously  in  an  intra- 


Fig.  6. — Formation  of  an  intradermal  wheal  (Braun). 

dermal  line  (Figs.  7,  8,  and  9),  or  the  long  needle  on  the  large  syringe 
can  be  advanced  through  the  "station"  to  subcutaneous  or  deeper 
parts  and  paraneural  or  other  injections  made  as  indicated  (Figs.  10, 
n,  12,  13).  The  proper  method  of  anesthetizing  the  skin  by  intra- 
dermal injections  was  first  taught  us  by  Schleich  and  Reclus;  for 


Fig.  7. — Illustrating  technic  of  cutaneous  infiltration  (Schleich  method)  (Braun). 

this  purpose  the  needle  should  be  advanced  in  the  deeper  planes  of 
the  skin  (the  papillary  layer  contains  the  nerve-end  organs);  the 
needle  is  inserted  within  the  margins  of  the  anesthetic  wheal  first 
made  and  progressively  advanced,  injecting  the  solutions  as  the 
needle  is  being  pushed  forward,  developing  a  ridge  of  infiltration 


i78 


LOCAL   ANESTHESIA 


Fig.  8 


Fig.  9 
Figs.  8,  9. — Intradermal  infiltration  (after  Reclus)  (Braun). 


Fig.  10. — Subcutaneous  infiltration  from  opposite  points  of  entrance  (Braun). 


PRINCIPLES    OF    TECHNIC 


179 


edema  along  the  line  of  injection.  When  the  needle  is  reintroduced, 
this  should  always  be  done  just  within  the  margins  of  the  last  in- 
jection, otherwise  each  additional  needle  stick  will  be  felt. 


Fig.  ii. — Methods  of  making  subcutaneous  injections  (Braun). 


Fig.  12. — Schematic  representation  of  cross-section  through  forearm  and  method  of 
infiltration  from  four  points  (Braun). 


Fig.  13. — Method  of  producing  a  plane  of  anesthesia  in  subcutaneous  or  other  tissues, 
when  injecting  beneath  a  tumor,  etc.     (Braun). 

The  same  plan  is  followed  in  anesthetizing  a  tract  for  aspiration 
or  exploratory  puncture — we  will  say,  for  illustration  of  the  pleural 
cavity.  This  method  of  procedure  is  clearly  shown  in  Fig.  14. 


i8o 


LOCAL   ANESTHESIA 


In  making  an  injection  over  a  wide  area  subcutaneously,  or  in 
the  deeper  planes  of  tissues,  one,  two,  or  more  points  are  first  anes- 
thetized on  the  overlying  skin,  and  the  needle  advanced  in  various 


Skin 


Muscle  'V,  ;'•. 


Pleura 


Fig.  14. — Method  of  infiltrating  successive  planes  of  tissue  for  exploratory  puncture  or 

aspiration  (Braun). 

directions,  continuously  injecting  as  the  needle  is  pushed  to  deeper 
depths,  and  withdrawing  the  needle  only  sufficiently  to  direct  its 
point  in  another  direction,  thus  avoiding  repeated  unnecessary  punc- 


V      ~^  ,                                                          ^"    ,'            / 

Subcutanec 

Vv                          ^      **                     /                                   f 
\                                        N                                                     X                                         / 
\                                           V                                 r>'                                           ' 

V                       j|                            X-j       i'                             /                      ^ 

/  Fascia  and 
/      muscle 

^^^^ 

yjj^  Bone 

Fig.  15. — Method  of  infiltrating  several  planes  of  tissue,  including  underlying  bone  from 
two  points  of  injection  (Braun). 

tures  of  the  skin.     This  is  illustrated  schematically  in  Figs.  15  and 
16. 

In  making  the  injections  they  should  not  be  too  rapidly  done,  as 
the  sudden  distention  of  the  tissues  may  cause  pain  or  rupture  of 
delicate  parts. 


PRINCIPLES    OF   TECHNIC 


181 


While  it  is  generally  advisable  to  precede  any  incision  by  an  in- 
tradermal  infiltration  along  the  proposed  line,  this  is  not  invariably 
necessary.  In  cases  where  extensive  dissections  are  to  be  under- 
taken, the  massive  infiltration  of  the  subcutaneous  tissues  reaches 
and  anesthetizes  the  nerves  in  their  course  to  the  skin;  an  indirect 
method  of  anesthesia.  • 


Fig.  16. — Method  of  anesthetizing  area  of  bone  from  two  puncture  points  in  surrounding 

soft  parts  (Braun). 

COLD 

The  sedative  influence  of  cold  when  used  alone  has  already  been 
mentioned.  Here  a  brief  reference  will  be  made  to  its  intensifying 
effects  upon  the  anesthetic  solutions. 

Experimentation  led  to  the  information  that  cold  solutions  ex- 
erted a  more  pronounced  effect  than  those  used  at  body  tempera- 
ture, but  when  injected  cold  they  excited  pain  in  proportion  to  the 
lowness  of  their  temperature;  it  was  accordingly  recommended  that 
they  be  injected  at  ordinary  temperature  and  the  area  then  cooled; 
this  was  done  by  packing  it  in  ice  or  by  the  use  of  sterile  bags  filled 
with  ice;  this  refrigeration  of  the  injected  area  was  practised  some 
years  ago,  but  is  now  rarely  ever  employed.  Ethyl  chlorid  spray  was 
also  used  upon  the  surface  to  produce  this  refrigeration.  To  favor 


182  LOCAL   ANESTHESIA 

the  diffusion  of  the  anesthetic  solutions  they  were  often  injected  warm 
and  the  cold  later  added  to  intensify  the  effect. 

The  injection  of  solutions  at  temperature  noticeably  above  or 
below  that  of  the  body  always  excites  pain,  while  the  injection  of  such 
solutions  as  are  advocated  in  this  volume,  at  body  or  room  tempera- 
ture, at  which  point  they  should  always  be  used,  is  absolutely  devoid 
of  any  appreciable  sensation. 

REGIONAL  ANESTHESIA 

Regional  methods  of  anesthesia  include  all  those  methods  which 
control  sensation  of  a  peripheral  part  or  area  of  distribution,  of  any 
nerve  or  plexus  of  nerves,  or  of  any  artery,  by  proximal  injections 
into  the  trunk  of  the  nerve  or  lumen  of  the  vessel  some  distance  from 
the  peripheral  distributions.  The  same  results  are  obtained  by 
Bier's  intravenous  anesthesia,  and,  in  a  broader  sense,  by  spinal 
analgesia. 

The  following  is  a  classification  of  regional  methods: 

Paraneural,  injections  made  in  contact  with  a  nerve. 

Intraneural,  injections  made  within  a  nerve. 

Spinal  analgesia  (including  epidural  injections  of  Cathelin) . 

Intravenous  anesthesia  (Bier). 

Intra-arterial  anesthesia. 

Hackenbruch  regional  anesthesia,  by  circumferential  injections. 

By  these  methods  the  operator  is  often  able  to  demonstrate  the 
high  state  of  perfection  to  which  purely  local  methods  of  anes- 
thesia have  been  developed.  These  procedures  may  be  divided  into 
the  paraneural  (indirect)  and  intraneural  (direct)  methods.  Spinal 
analgesia  is  also  a  regional  method,  which  is  discussed  under  a 
separate  heading. 

A  paraneural  injection  is  made  by  inserting  a  needle  into  the  tis- 
sues to  the  known  position  of  a  nerve-trunk  and  there  making  the 
injection;  the  solution  surrounding  the  nerve- trunk  envelops  it  in 
an  anesthetic  atmosphere,  which  gradually  diffuses  itself  into  the 
nerve-tissue.  Obviously,  an  injection  thus  made  should  be  of  larger 
quantity  and  greater  strength  than  when  made  directly  into  the  sub- 
stance of  the  nerve,  as  in  the  intraneural  method;  when  such  an  in- 
jection is  accurately  made,  and  the  solution  deposited  in  close  con- 
tact with  a  nerve-trunk,  time  being  allowed  for  thorough  diffusion, 
anesthesia  of  the  entire  nerve  distribution  will  result.  This  method 
is  clearly  open  to  objections,  as  many  errors  are  likely  to  result;  in 
cases  where  the  injection  has  not  been  accurately  placed,  no  anes- 


PRINCIPLES   OF   TECHNIC  183 

thesia  will  result;  also  it  is  possible  to  injure  other  structures  or  to 
make  the  injection  into  a  vessel.  This  method  may  often  be  re- 
garded as  unsurgical,  and  is  hardly  to  be  recommended  where  more 
exact  methods  can  be  employed;  however,  it  may  be  necessary  under 
certain  anatomic  conditions,  as  when  blocking  the  branches  of  the 
trigeminus  at  their  exit  from  the  skull  or  the  branches  of  the  pudic 
nerve  near  the  base  of  the  tuberosity  ischium.  In  making  the  in- 
jections in  the  above  cases,  and  elsewhere  in  positions  where  large 
veins  may  be  encountered,  it  is  advisable  never  to  make  the  injec- 
tion when  the  point  of  the  needle  is  stationary,  but  always  when  it 
is  being  advanced  or  withdrawn;  or  after  the  exact  position  has  been 
reached  by  the  point  of  the  needle,  slight  aspiration  on  the  syringe 
can  be  made  to  determine  if  a  vein  has  been  entered,  before  making 
the  injection. 

In  such  cases  the  injection  of  the  solution  into  a  vein  is  more  to 
be  avoided  than  its  introduction  into  an  artery;  the  puncture  of 
either  vessel  by  a  fine  needle  is  not  in  itself  of  any  consequence,  as 
no  hemorrhage  is  likely  to  occur  from  such  a  small  puncture.  We 
purposely  make  such  punctures  at  times  in  intra-arterial  anesthesia, 
where  we  wish  to  anesthetize  the  area  of  distribution  of  a  particular 
artery  and  use  the  arterial  blood  as  a  means  of  distributing  the 
solution  to  the  tissues;  but  in  making  the  injection  into  a  vein  the 
concentrated  solution  is  carried  at  once  into  the  general  circulation 
and  may  reach  the  higher  nerve-centers  in  such  quantity  as  to  pro- 
duce serious  toxic  results.  We  must  remember  that  the  intravenous 
administration  of  cocain  is  the  most  toxic;  the  toxicity  of  any  injec- 
tion of  cocain  depends  upon  the  concentration  of  the  solution  and 
the  amount  reaching  the  circulation  at  any  one  time,  and  here  we 
would  have  the  maximum  action. 

While  the  intra-arterial  injection  is  to  be  avoided  as  an  accidental 
occurrence,  it  is  never  as  toxic  as  the  intravenous  administration. 
The  solution  has  first  to  travel  through  the  ultimate  distribution  of 
the  artery  and  the  capillaries,  and  if  adrenalin  is  used  these  are  com- 
pletely occluded  together  with  the  arterioles  leading  to  them  by  the 
first  contact  of  the  adrenalin.  This  response  to  adrenalin  is  imme- 
diate, the  solution  is  thus  retained  for  some  time  in  contact  with  the 
tissues  and  its  action  largely  reduced  before  it  is  finally  carried  by 
the  return  circulation  to  the  heart.  In  the  case  of  a  vein,  if  of  any 
size,  this  action  of  adrenalin  is  insufficient  to  occlude  it. 

The  intraneural  (direct  method)  is  more  accurate,  and  decidedly 
to  be  preferred  whenever  possible.  It  is  applicable  to  any  large 


1 84 


LOCAL   ANESTHESIA 


nerve- trunks,  brachial  (above  the  clavicle),  ulna,  median,  and 
musculo-spiral  at  the  bend  of  the  elbow,  or  at  any  other  accessible 
points  along  their  course,  also  the  sciatic  and  its  divisions  in  the  thigh 
and  leg.  This  method  was  first  perfected  by  Gushing,  Crile,  and 


Fig.  17. — Apparatus  for  rapid  massive  infiltration  anesthesia.      Charging  the  cylinder 

with  air-pump  (Matas). 

Matas;  as  it  is  discussed  in  detail  in  the  surgery  of  the  extremities 
it  will  not  be  repeated  here.  This  method  is  also  utilized  in  the  course 
of  any  operation  whenever  nerves  are  encountered,  as  in  herniotomies, 
thoracotomies,  etc. 


Fig.  18. — Cylinder  charged  and  inverted.      The  pumping  outfit  is  detached  when  the 
apparatus  is  in  operation  (Matas). 

The  method  of  making  the  intraneural  injection  is  of  importance; 
the  nerve  should  not  be  pinched  up  by  forceps  or  other  instruments, 
as  any  such  manipulations  cause  pain  referred  to  its  peripheral  dis- 
tribution, and  may  be  sufficiently  severe  to  make  the  patient  cry  out 
or  lose  confidence  in  the  promise  of  a  painless  operation;  the  injec- 


PRINCIPLES    OF   TECHNIC  185 

tion  should  be  made  with  the  nerve  lying  in  its  bed,  by  inserting  a 
fine  needle  in  the  long  axis  of  the  nerve,  first  within  its  sheath,  which 
is  edematized;  the  needle  is  then  gently  advanced  between  the  dif- 
ferent nerve-bundles  and  the  infiltration  continued  until  the  nerve 
presents  a  fusiform  swelling  at  this  point,  this  may  require  from 
5  to  15  minims  of  solution. 

Complete  anesthesia  of  its  entire  distribution  usually  results  in 
from  five  to  ten  minutes,  but  may  exceptionally  be  delayed  to  twenty 
minutes  or  longer.  After  making  the  injection  the  wound  made  to 
expose  the  nerve  should  not  be  immediately  closed,  but  loosely  ap- 
proximated by  stitches  and  protected  by  dressings,  as  it  may  occa- 
sionally be  necessary  to  make  additional  injections,  particularly  if 
the  operation  is  at  all  protracted. 

Regional  anesthesia  may  also  be  employed  by  the  Schleich  infil- 
tration method  by  creating  a  circular  ring  of  infiltration  edema 
around  a  peripheral  part,  such  as  a  finger,  and  might,  in  exceptional 
cases,  be  utilized  higher  up  on  the  extremities  when  quite  thin,  and 
in  parts  where  the  nerves  which  are  encountered  are  not  of  such 
size  as  cannot  readily  be  penetrated  in  effective  quantities  by  the 
weak  infiltrating  fluid.  The  above  method  while  simple,  effective, 
and  often  quickly  executed,  with  suitable  instruments,  such  as  the 
Matas  infiltrator  (Figs.  17  and  18),  is  not  to  be  recommended  when 
regional  methods  or  vein  anesthesia  can  be  applied. 

Conditions  may,  however,  arise  in  which,  through  lack  of  facili- 
ties or  lack  of  technic,  vein  anesthesia  cannot  be  carried  out,  and 
amputation  or  other  extensive  operation  on  the  peripheral  part  is 
necessary.  Sometimes,  owing  to  unhealthy  conditions  of  the  tis- 
sues, nephritis,  diabetes,  etc.,  particularly  when  complicated  by 
cardiac  or  pulmonary  disease,  it  becomes  desirable  to  reduce  the 
number  of  incisions  to  a  minimum;  in  such  conditions,  when  the 
field  of  operation  is  in  the  region  of  large  nerves,  a  combined  method 
of  procedure  may  be  followed.  First  thoroughly  edematize  the 
entire  thickness  of  the  limb;  the  large  nerve- trunks  can  then  be 
sought  for  as  the  operation  progresses  and  blocked  by  an  intraneural 
injection,  slightly  proximal  to  the  field  by  slightly  stronger  solutions 
than  that  used  for  the  infiltration,  when  they  can  be  then  safely 
divided.  This  method,  while  open  to  objections,  may  still  be  the 
method  of  choice  under  certain  extreme  conditions ;  true,  the  edema- 
tization  of  the  field  may  favor  suppuration  in  badly  diseased  or 
devitalized  tissues,  yet  in  cases  of  amputation  it  is  at  a  favorable 
site  for  drainage  should  suppuration  occur,  and  may  offer  the  best 


i86 


LOCAL   ANESTHESIA 


and  safest  means  of  getting   rid   of  an   offending  member  when 
gangrenous  or  otherwise  diseased. 

Hackenbruch  recommended  a  method  of  regional  anesthesia, 
which  he  called  circular  anesthesia,  by  creating  a  wall  of  infiltration 
edema  around  the  region  to  be  operated  upon,  and  in  this  way  inter- 
rupts the  conductivity  of  all  nerves  entering  the  area  (Fig.  19).  This 
is  a  highly  useful  method,  but  applicable  only  to  limited  areas,  for, 
if  too  extensive,  nerves  may  enter  the  area  from  below  at  points 
which  cannot  readily  be  reached  by  the  infiltrating  solution.  When 
operating  by  this  method,  the  infiltration  of  the  entire  area  should 
be  completed  before  beginning  to  operate.  This  plan  is  particularly 
applicable  to  cysts,  carbuncles,  boils,  infected  and  inflamed  areas, 


of  cutouitous  Jlnestheaia. 
Surrounding  field  of  operation 


Vertical,  section  through  tissues  taking  in 
margin  of  infiltrated  area,  showing  method 
of  undermining  field  of  operation  with  a 
•wall  of  anesthetic  fluid. 

Fig.  19. — Shows  method  of  using  Hackenbruch  anesthesia  around  a  tumor,  carbuncle, 
or  other  superficially  situated  lesion. 

where  direct  infiltration,  of  the  inflamed  tissues,  is  to  be  avoided;  it 
is  also  useful  in  the  removal  of  epitheliomata  and  other  malignant 
disease,  when  superficially  situated  and  of  limited  extent;  this  method 
of  operating,  and  that  by  the  other  regional  methods,  are  the  only 
local  anesthetic  procedures  which  should  be  considered  when  deal- 
ing with  malignancy,  as  no  injections  should  be  made  which  approach 
the  limits  of  the  growths,  as  their  infiltration  may  produce  a  dis- 
semination of  the  cancer  cells  into  the  surrounding  tissues  or  general 
circulation. 

THE  CONSTRICTOR 

The  important  discovery  made  by  Corning  in  1885,  that  the  ac- 
tion of  cocain  can  be  indefinitely  prolonged  when  the  circulation  of  the 


PRINCIPLES    OF   TECHNIC  187 

part  is  arrested  by  the  use  of  constrictors  or  other  mechanical  devices, 
proved  a  decided  advantage  in  all  operations  upon  the  peripheral 
parts ;  since  the  advent  of  adrenalin,  the  therapeutic  constrictor,  this 
advantage  has  been  less  apparent,  but  nevertheless  of  decided  benefit 
in  many  cases.  Briefly,  the  advantages  of  constricting  and  arresting 
the  circulation  of  the  part  permit  an  indefinite  prolongation  of  the 
anesthesia.  In  addition,  by  prolonging  the  retention  of  the  anes- 
thetic agent  in  contact  with  the  tissue-cells,  with  which  it  becomes 
largely  fixed,  and  their  physiologic  activity  so  reduced  that  doses 
which  may  have  been  regarded  as  dangerous  or  toxic,  used  by  other 
methods,  can  often  be  safely  used;  or,  by  the  intermittent  relaxa- 
tion of  the  constrictor,  permitted  to  enter  the  system  gradually, 
so  that  no  untoward  symptoms  are  produced.  Obviously,  too,  the 
immediate  constriction  of  a  peripheral  part  will  arrest  further  absorp- 
tion in  cases  of  poisoning,  and  permit  the  system  to  recover  before 
more  is  allowed  to  enter  the  general  circulation. 

The  intensifying  effect  of  constriction  upon  the  anesthetic  influ- 
ence of  any  agent  used  is  further  emphasized  if  the  part  is  first 
rendered  ischemic;  if  blood  is  absent  from  the  part  with  its  diluting 
and  neutralizing  influence  removed,  the  drug  can  act  exclusively  upon 
the  tissue-cells  and  their  nerve-endings. 

The  method  of  applying  the  constrictor,  when  used  above  the 
anesthetized  area  on  normally  sensitive  parts,  is  a  point  which  should 
receive  careful  attention;  pressure  from  a  constrictor  carelessly 
applied  may  be  borne  without  complaint  for  a  short  time,  but  the 
continuous  pressure  soon  becomes  intolerable,  and  the  operation  is 
often  interrupted  by  having  to  stop  and  readjust  the  constrictor. 
This  is  best  avoided  by  applying  it  only  over  well-padded  parts, 
distributing  rolls  over  an  area  of  6  or  8  inches  in  width,  and  when 
possible  within  the  margin  of  the  anesthetized  area. 

TECHNIC  OF  HANDLING  WOUNDS  IN  GENERAL 

In  the  surgical  treatment  of  wounds,  such  as  contused  and  lacer- 
ated, incised,  punctured,  gunshot-  or  stab-wounds,  of  the  scalp,  face, 
and  other  parts  of  the  body,  requiring  suture,  incisions  for  freer 
drainage,  or  painful  manipulations  necessary  for  cleansing,  local  or 
regional  methods  of  anesthesia  may  often  be  used  to  great  advantage 
in  permitting  the  painless  handling  of  the  tissues  and  freedom  of 
work  necessary  to  thoroughly  cleanse  or  trim  up  ragged  or  crushed 
edges  or  insert  sutures.  When  these  wounds  are  of  small  extent  and 
superficially  situated,  purely  local  methods  of  anesthesia  will  suffice; 


1 88  LOCAL   ANESTHESIA 

where  they  are  very  extensive  or  involve  the  deeper  parts  or  im- 
portant structures,  such  as  penetration  or  opening  of  a  joint,  division 
of  tendons,  nerves,  or  other  important  structures,  and  even  under 
some  conditions  in  compound  fractures  or  crushing  or  mangling  of 
the  limbs,  regional  anesthesia  may  often  be  used  to  great  advan- 
tage, by  blocking  the  nerve-paths,  thus  preventing  shock  or  per- 
mitting painless  manipulations  necessary  for  the  repair  of  the 
damage. 

Where  purely  local  methods  of  anesthesia  are  used,  as,  for  instance, 
in  a  contused  and  lacerated  wound  of  the  scalp,  the  hair  should 
first  be  shaved  from  around  the  wound,  protecting  the  wound  mean- 
while with  a  compress;  this  surrounding  area  then  lightly  cleansed, 
and,  if  preferred,  painted  with  5  per  cent,  tincture  of  iodin.  The 
anesthesia  is  then  carried  out  as  indicated  in  Figs.  20  and  21,  the 
small  circles  indicating  the  points  in  the  skin  at  which  stations  of 
anesthesia  are  established  by  intradermal  infiltration;  the  dotted 
arrows  indicating  the  course  and  direction  of  a  long  needle,  which  is 
to  be  inserted  subcutaneously,  making  a  rather  free  injection  of  solu- 
tion as  the  needle  is  advanced,  so  as  to  create  a  wall  of  anesthesia 
which  will  entirely  embrace  the  wound;  the  depths  of  the  subcu- 
taneous injections  will,  of  course,  depend  upon  the  depth  of  the  wound; 
when  situated  upon  the  scalp  the  injection  should  be  carried  down 
to  the  pericranium;  when  situated  in  other  parts  of  the  body,  the 
injection  should  be  made  according  to  the  Hackenbruch  method, 
by  carrying  the  long  needle  down  into  the  tissues  to  below  the  depth 
of  the  wound,  but  always  keeping  outside  the  wound  in  the  surround- 
ing uninjured  tissues;  the  injections  should  be  made  more  liberally 
in  the  subcutaneous  tissues,  as  it  is  here  that  the  sensory  nerves  are 
more  freely  distributed  in  their  course  to  the  overlying  skin;  the 
deeper  parts,  being  more  sparsely  supplied  with  sensory  nerves,  will 
not  require  such  free  injections  unless  along  the  course  of  recognized 
nerve-paths. 

After  the  anesthetizing  procedure  has  been  thoroughly  carried 
out,  the  compress  may  be  removed  from  over  the  wound  and  the 
entire  area  freely  cleansed  by  further  shaving  if  necessary,  and  the 
wound  washed  out  or  irrigated  and  otherwise  treated,  as  the  indica- 
tions require,  with  a  freedom  of  manipulation  so  necessary  for 
thorough  work  that  is  rarely  possible  except  in  anesthetized 
tissues. 

Fig.  2 1  shows  a  contused  and  lacerated  wound  with  undermined 
edges;  it  is  to  be  treated  the  same  as  Fig.  20;  the  radiating  lines  from 


PRINCIPLES    OF    TECHNIC 


189 


the  area  of  laceration  will  require  slitting  up  to  permit  access  to  and 
drainage  from  the  deeper  parts. 

Poisoned  wounds  from  snake-bites,  rabid  animals,  or  other 
dangerous  sources  will  require  handling  as  expeditiously  as  possible; 
this  may  not  permit  of  the  use  of  local  anesthesia,  although  in  the 
hands  of  those  skilled  in  its  use  but  a  very  few  minutes  are  required 
for  the  infiltration,  which  of  course  should  always  be  carried  out  by 
the  above-mentioned  Hackenbruch  plan,  keeping  well  away  from 
the  possible  area  of  infection,  and  never  by  making  the  injections 
directly  into  the  wounds.  Many  such  wounds  occur  in  surround- 
ings where  the  necessary  facilities  and  instruments  are  not  at  hand 


Figs.  20  and  21. — Method  of  surrounding  scalp  or  other  cutaneous  wounds  with  zone 

of  anesthesia  (Braun). 

for  the  practice  of  local  anesthesia,  or  any  other  form,  and  the  indi- 
cations may  be  sufficiently  urgent  to  demand  a  heroic  procedure  to 
remove  or  lessen  the  influence  of  the  poison  without  any  anesthetic. 
However,  many  cases  will  present  themselves  where  the  indications 
are  not  so  urgent;  here  the  application  of  a  constrictor  will  prevent 
any  further  absorption,  and  the  few  minutes  delay  necessary  for  the 
anesthesia  will  be  more  than  repaid  by  the  greater  facility  and  thor- 
oughness with  which  incisions  or  cauterizations  can  be  carried  out, 
and  the  great  satisfaction  on  the  part  of  the  medical  attendant  that 
he  is  not  inflicting  pain  on  a  screaming  and  writhing  but  otherwise 
willing  patient. 


IQO  LOCAL   ANESTHESIA 

Wounds  of  the  palm  of  the  hand  or  sole  of  the  foot,  but  especially 
the  latter  in  hard-working  people,  where  the  tissues  are  dense  and 
leathery,  are  often  very  unsatisfactory  for  treatment  by  any  method 
of  infiltration;  the  infiltration  of  such  dense  tissues  is  often  very 
difficult  and  frequently  accompanied  by  a  great  deal  of  pain  to  the 
patient,  even  though  quite  strong  solutions  are  used.  1  have  often 
seen  the  barrel  of  the  ordinary  hypodermic  syringe  break  under  the 
pressure  necessary  for  infiltration  in  such  cases.  It  is  far  simpler 
and  more  satisfactory,  both  to  physician  and  patient,  to  practice  an 
intra-  or  paraneural  injection,  as  described  in  the  chapter  on  Surgery 
of  the  Extremities. 

HEMOSTASIS  AND  CLOSURE  OF  WOUNDS 

The  closure  of  any  operative  wound  made  under  local  anes- 
thesia where  adrenalin  is  a  constituent  of  the  solutions  used  calls 
for  increased  care  and  thoroughness  in  securing  all  bleeding-points, 
even  the  smallest  ooze,  for  what  appears  at  the  time  of  no  conse- 
quence may,  as  the  effects  of  the  adrenalin  subsides,  increase  and 
give  rise  to  hematoma,  which  may  jeopardize  the  results  of  an  other- 
wise satisfactory  operation.  To  prevent  such  consequences,  hemo- 
stasis  should  be  perfect,  and  it  is  also  advisable  to  anchor  the  over- 
lying planes  of  tissue  to  the  ones  beneath  during  closure  to  obliterate 
the  possibility  of  any  dead  space.  The  skin  sutures  should  not 
be  drawn  too  tightly,  but  should  allow  of  the  escape  of  serum  from 
the  wound  should  any  collect.  A  firm,  snug,  bandage,  exerting  a 
moderate  amount  of  pressure,  is  also  a  valuable  adjunct  as  a  final 
step  in  the  case. 

THE  HISTORY  OF  THE  HYPODERMIC  SYRINGE 

The  invention  of  the  hypodermic  syringe,  that  wonderfully  useful 
instrument,  is  generally  credited  by  most  writers  to  Wood  in  1855. 
However,  the  idea  seems  to  have  originated  with  Monteggia  (1813), 
who  suggested  the  use  of  a  cannula  for  this  purpose.  But  the  real 
credit  for  the  invention  of  the  modern  hypodermic,  as  we  know  it 
to-day,  according  to  the  investigations  of  Pfender  ("Washington 
Med.  Ann.,"  vol.  x,  No.  6),  who  reviewed  the  literature  thoroughly, 
seems  undoubtedly  to  belong  to  F.  Rynd,  an  Irish  surgeon,  who 
introduced  the  instrument  in  1845.  Pravez  in  1851  introduced  a 
cannula  of  capillary  size,  following  out  the  idea  of  Monteggia,  which 
was  used  for  injections.  In  1885  Wood  first  wrote  on  the  subject  of 


PRINCIPLES    OF   TECHNIC  IQI 

the  syringe,  and  popularized  it  through  his  numerous  writings  and 
brilliant  demonstrations,  but  the  real  discoverer  seems  undoubtedly 
to  have  been  Rynd. 

The  French  manufacturers  in  1862  introduced  an  excellent  in- 
strument which  would  compare  favorably  with  those  of  today,  but, 
even  with  this  hypodermic,  it  was  recommended  that  its  use  be 
preceded  by  the  Richarson  ether  douche,  as  the  ether  spray  was 
then  called.  Rapid  improvements  in  manufacture  followed,  until 
we  have  the  perfected  instrument  of  to-day. 


CHAPTER  IX 

THE  USE  OF  MORPHIN  AND  SCOPOLAMIN  AND  COMBINED 
METHODS  OF  ANESTHESIA 

MORPHIN  AND  SCOPOLAMIN 

IT  is  hard  to  determine  exactly  when  morphin  and  other 
synergistic  drugs  were  first  used  as  a  preliminary  or  preparatory 
treatment  to  operations  under  local  anesthetics.  The  discovery  of 
morphin  considerably  antedates  that  of  cocain,  and  its  hypodermic 
use  began  with  the  introduction  of  the  hypodermic  syringe  by  Rynd 
in  1845,  when  it  was  used  extensively  as  an  injection  into  the  site 
of  pain  for  such  affections  as  neuralgia,  pleurodynia,  arthritis,  etc., 
with  the  idea  then  prevailing  that  it  exercised  a  considerable  local 
as  well  as  constitutional  action.  The  prevalence  of  these  ideas  no 
doubt  largely  influenced  medical  thought  later  when  morphin  was 
combined  with  cocain  in  local  anesthetic  mixtures,  such  as  in  the 
Schleich  solutions.  These  views  were  found  to  be  largely  in  error. 
Morphin  does  exert  a  certain  limited  local  action,  but  it  is  necessary 
to  use  4  per  cent,  solutions  to  produce  any  decided  local  analgesic 
effect,  a  concentration  clearly  beyond  any  possible  consideration;  it 
is,  therefore,  more  rational  to  give  the  morphin  separately  and  pre- 
ceding the  operations,  rather  than  to  include  it  in  the  anesthetic  solu- 
tion, for,  if  used  in  an  effective  strength  in  these  solutions,  in  many 
operations  where  an  undetermined  amount  of  solution  will  be  used, 
a  toxic  amount  of  the  drug  may  be  given.  What  is  decidedly  better 
is  to  administer  a  definite  dose  of  morphin  separately  and  before  the 
operation — besides,  the  aim  should  be  to  simplify  rather  than  com- 
plicate the  anesthetic  solution;  it  should  accordingly  contain  no  agent 
which  is  not  of  decided  value  locally,  either  for  its  anesthetic  action 
or  vasoconstriction,  as  adrenalin,  or  NaCl,  used  to  make  the  solution 
more  nearly  isotonic  with  the  blood. 

However,  the  discovery  that  the  central  analgesic  effect  of  mor- 
phin on  the  cortex  and  psychic  centers  greatly  assists  in  preparing 
the  mental  attitude  of  the  patient  for  the  action  of  local  anesthet- 
ics has  materially  contributed  to  the  success  of  local  and  regional 
anesthesia. 

This  suggestion  independently  occurred  to  many  operators  simul- 

192 


THE   USE    OF   MORPHIN   AND    SCOPOLAMIN  1 93 

taneously,  but  Ceci,  of  Genoa,  has,  since  1897,  insisted  upon  the 
systematic  use  of  morphin  as  a  preliminary  to  local  anesthesia,  and 
the  value  of  the  suggestion  has  been  recognized  in  almost  all  clinics 
where  local  anesthetics  are  most  frequently  followed.  The  ad- 
vantages in  the  use  of  morphin,  in  doses  of  Y§  to  34  gr->  given  hypo- 
dermically  from  one-half  to  one  hour  before  any  major  operation 
under  local  anesthetics  as  a  preparatory  injection,  are  many  and  are 
quite  apparent  to  those  who  resort  often  to  these  measures.  Here 
it  may  be  well  to  refer  to  the  chapter  on  Pain,  particularly  the  psychic 
control  over  pain,  to  better  understand  the  advantages  of  this  pro- 
cedure. The  mental  state  of  attention  and  anticipation  influences 
the  acuteness  of  painful  impressions;  it  must,  indeed,  be  a  trying 
ordeal  on  nervous  patients  to  undergo  an  operation  of  any  magnitude 
by  purely  local  means  of  anesthesia.  When  all  the  senses  are 
thoroughly  active,  anticipating  the  first  touch  of  the  knife,  when 
tactility  is  often  interpreted  as  pain,  when  the  strange  surroundings 
of  the  operating-room  add  to  the  nerve  tension,  the  natural -feeling 
of  dread  and  anxiety  on  the  part  of  the  patient  may  be  allayed  by  the 
use  of  morphin  or  other  opiates  given  hypodermically. 

Some  individuals  of  placid  or  phlegmatic  temperament,  who 
have  confidence  in  the  operator,  are  quite  satisfied  with  his  promise 
that  there  will  be  no  pain,  but  many  others,  nervous  or  high-strung 
individuals,  are  not  so  fortunate  temperamentally,  and  become  rest- 
less and  uneasy,  and  will  find  one-half  hour  or  an  hour  spent  on  the 
operating  table  in  itself  quite  a  severe  trial,  although  they  actually 
experience  no  pain,  but  are  conscious  of  the  operation  being 
performed. 

With  such  patients  it  is  highly  desirable  to  substitute  a  more 
placid,  tranquil  mental  stage  for  that  of  anxiety  and  uneasiness;  this 
is  best  insured  by  the  administration  hypodermically  of  %  to  }/±  gr. 
of  morphin,  either  alone  or  in  combination  with  scopolamin,  ^{50 
gr.,  about  one  hour  before  operation;  this  induces  a  drowsy,  pleasant 
state  of  mind,  and  the  patient  approaches  the  operating-room  in 
a  cheerful  attitude,  in  marked  contrast  to  many  not  so  treated,  who 
are  fearful  and  trembling,  and  declare  at  the  last  minute  that  they 
do  not  feel  equal  to  the  ordeal.  (See  chapter  on  Anoci-association 
for  effects  of  fear  upon  the  central  nervous  system.) 

There   are   other  advantages  in   this  preliminary  hypodermic, 

as  both  morphin  and  scopolamin  congest  the  cerebrum.     Cocain,  in 

exerting  a  toxic  influence,  is  supposed  to  produce  an  anemia  or  vaso- 

constriction  centrally,  the  same  as  it  does  locally,  as  an  initial  phenom- 

13 


194  LOCAL   ANESTHESIA 

enon  in  its  toxic  action;  while  morphin  is  not  the  ideal  antagonist, 
as  discussed  in  the  chapter  on  Toxicology,  it  nevertheless  does  seem 
to  exert  a  prophylactic  influence  in  preventing  the  development  of 
toxic  symptoms;  this  is  particularly  so  in  nervous  excitable  indi- 
viduals, who  are  undoubtedly  more  likely  to  develop  unpleasant 
symptoms,  even  if  nothing  more  than  a  slight  palor,  nausea,  or  un- 
easiness. These  manifestations,  as  well  as  other  unpleasant  dis- 
turbances and  reflexes,  are  all  less  likely  to  occur  following  the 
preliminary  hypodermic. 

As  spoken  of  elsewhere,  when  toxic  symptoms  arise  it  is  due  to 
the  use  of  an  excess  of  the  drug  beyond  that  needed  to  produce  com- 
plete local  anesthesia,  the  result  of  too  strong  solutions,  poor  technic, 
or  its  injudicious  use.  Personally,  I  have  never  had  any  toxic  symp- 
toms to  combat,  but  in  highly  susceptible  individuals,  with  marked 
idiosyncrasy,  such  disturbances  may  occur,  and  it  is  well  to  forestall 
their  development  if  possible.  The  effect  of  such  a  hypodermic  is 
quite  lasting,  six  to  eight  hours,  and  often  eliminates  the  necessity  of 
a  postoperative  injection  being  needed  for  after-pains. 

Two  such  agents  as  morphin  and  scopolamin  in  combination, 
while  not  syngergistic  in  the  entire  range  of  their  action,  are  in  so  far 
as  they  dull  the  mentality  and  produce  a  tranquil  somnolent  state; 
morphin,  acting  more  especially  in  its  influence  over  pain,  while 
scopolamin  is  used  entirely  for  its  somnolent  effect.  This  idea  of 
the  combination  of  such  narcotics  as  morphin  and  scopolamin,  which 
are  extensively  used  together,  bear  out  Burgi's  contention  that  the 
sum  of  the  combined  action  of  two  or  more  narcotics  administered 
simultaneously,  or  shortly  after  each  other,  produce  a  much  more 
powerful  effect  than  when  a  total  equivalent  quantity  of  either  one 
narcotic  had  been  administered  alone.  This  increased  action  is 
particularly  marked  when  the  two  narcotics  have  different  cell 
receptors,  or  belong  to  different  chemical  series,  in  which  case  the 
two  drugs  seem  to  potentiate  each  other,  and  that  a  dose  of  any  one 
drug  acts  much  more  markedly  when  given  in  frequent  small  doses 
than  when  administered  at  once  in  a  single  dose;  this  last  part  of  his 
contention  is,  however,  not  of  value  to  us  here. 

Other  advantages  of  the  preliminary  hypodermic  are  that  it 
seems  to  intensify  and  prolong  the  action  of  the  local  anesthetic 
used,  either  by  removing  the  psychic  state  favorable  to  the  develop- 
ment of  pain  or  by  dulling  the  pain  perception  centers,  enabling  the 
operator  to  succeed  with  minimum  amount  of  the  anesthetic  solu- 
tion. This  last  view  is  entirely  in  accord  with  Burgi's  contention; 


THE   USE    OF   MORPHIN   AND    SCOPOLAMIN  1 95 

the  morphin  centrally  is  synergistic  to  the  action  of  the  cocain 
locally. 

The  central  action  of  cocain  and  other  local  anesthetics  following 
the  usual  surgical  doses  is  one  of  stimulation  and  after  large  doses 
a  subsequent  depression  particularly  of  the  respiratory  centers. 
The  physiological  action  of  scopolamin,  morphin,  pantopon  and 
other  opiates,  by  dulling  the  higher  nerve  centers  entirely  prevents 
the  stimulating  effect  of  cocain,  and  this  same  action  on  all  the  nerve 
centers  lessens  their  suceptibility  to  other  influences.  Clinical  ex- 
perience has  well  demonstrated  that  when  the  nervous  system  is 
under  the  influence  of  such  drugs,  very  much  larger  doses  of  local 
anesthetics  can  be  safely  used  for  their  peripheral  action. 

Thus  the  use  of  opiates  serve  a  double  purpose  in  diminishing 
or  entirely  preventing  the  psychic  strain,  as  well  as  permitting  the 
use  of  larger  doses  of  the  anesthetic.  It  has  further  been  amply 
proven  that  it  prevents  to  some  extent  the  damage  to  the  organs  of 
the  kinetic  system  resulting  from  the  trauma  of  the  operation,  as  it 
has  been  shown  both  in  the  laboratory  as  well  as  in  the  clinic  that 
deep  morphinization  can  completely  prevent  the  development  of 
shock.  In  preparing  special  risks  for  operation,  and  those  who 
claim  to  possess  idiosyncrasies,  it  is  well  to  give  a  tentative  hypo- 
dermic during  the  period  of  preparation  to  observe  its  effects. 
While  advocating  the  single  preliminary  injection  of  the  two  agents 
in  medium-sized  doses  as  desirable  in  nervous  and  excitable  indi- 
viduals, as  a  means  of  allaying  this  excitement  and  thus  protecting 
the  patient  against  himself,  we  do  not  invariably  make  use  of  the 
procedure  except  in  operations  of  considerable  magnitude,  and  never 
use  it  as  a  means  of  anesthesia  alone,  and  wish  to  very  positively 
condemn  such  a  practice  as  highly  dangerous  and  unsurgical,  to  say 
the  least. 

The  idea  of  using  these  two  drugs  for  anesthesia  alone  or  in  com- 
bination with  cactin  or  other  agents  is  fraught  with  the  greatest  risk 
possible,  and  had  its  origin  in  the  suggestion  in  1900  by  Schneiderlin 
that  they  be  used  in  large  doses  as  a  means  of  producing  surgical  anes- 
thesia. This  idea  was  founded  on  an  erroneous  conception  that  the 
two  drugs  exerted  a  certain  cardiac  and  respiratory  antagonism  while 
being  synergistic  in  their  analgesic  and  hypnotic  qualities;  this, 
however,  was  soon  shown  to  be  an  error,  and  Wood  in  1905  was  able  to 
collect  2000  cases  with  9  deaths,  or  i  to  221 — a  frightful  mortality — 
and  in  69  per  cent,  of  the  cases  a  general  anesthetic  was  necessary 
to  complete  the  operation. 


196  LOCAL   ANESTHESIA 

This  method  when  condemned  in  general  surgical  practice  was 
later  taken  up  by  obstetricians  of  the  Friburg  school  and  exploited 
as  "Twilight  Sleep."  Here  as  in  general  surgery  its  use  is  irrational 
and  unsafe  and  it  will  undoubtedly  be  abandoned.  The  substitu- 
tion of  pantopon,  or  narcophen  for  the  morphin  does  not  in  any  way 
alter  the  objection. 

A  few  words  regarding  the  action  of  scopolamin  may  not  prove 
uninteresting.  Scopolamin  hydrobromid  is  claimed  by  some  to  be  an 
impure  hyoscin  hydrobromid;  however,  its  action  seems  identical 
with  the  latter  drug.  Its  principal  action  is  upon  the  cerebrum, 
inducing  sleep;  it  is  also  feebly  depressant  to  the  spinal  cord,  but  it 
exerts  no  influence  as  an  analgesic. 

The  pulse-rate,  while  usually  slightly  lessened,  is  not  markedly 
affected.  The  respiration  is  depressed  by  large  doses,  but  seems  little 
or  not  at  all  affected  by  medium  doses,  Y\w  gr.;  when  death  does 
occur,  which,  however,  is  said  to  be  extremely  rare,  with  even  very 
large  doses,  it  occurs  as  the  result  of  asphyxia;  7}-^  gr.  have  been  in- 
jected intravenously  into  a  dog  without  destroying  life. 

The  skin  is  usually  quite  moist  following  its  action,  the  nose, 
throat,  and  mouth  dry,  and  the  pupils,  as  a  rule,  dilated. 

According  to  Metzenbaum,  scopolamin  acts  as  though  it  had 
two  radicals,  one  acting  as  a  cerebral  sedative  and  soporific,  allay- 
ing fear  and  excitement  and  usually  producing  sleep;  the  other 
radical  acts  much  like  atropin,  drying  the  secretions  of  the  mouth, 
pharynx  and  bronchi  and  dilating  the  pupils. 

In  my  own  experience  scopolamin  is  a  dangerous  drug  if  used 
injudiciously.  The  dose  should  rarely  exceed  ^50  gr.  and  never 
more  than  J-foo  and  it  is  preferable  to  use  the  smaller  dose. 

Its  usual  action  in  moderate  doses  is  that  of  a  sedative  and  hyp- 
notic, and  when  combined  with  morphin  but  especially  pantopon 
this  action  is  intensified.  Its  over  action  resembles  that  of  atropin 
in  producing  excitement  and  delirium. 

It  seems  more  than  a  coincidence  that  in  several  cases  in 
which  the  above  dose  was  increased  by  accident  the  patients  became 
flighty  at  intervals  for  several  days  following  operation,  removing 
dressings  and  attempting  to  get  out  of  bed.  In  one  case  these  spells 
recurred  for  as  long  as  a  week  afterward.  When  spoken  to,  the 
patients  would  correct  their  behavior  and  seem  in  all  respects  per- 
fectly normal,  but  would  revert  to  the  disturbed  mental  state  when 
left  alone.  This  action  has  seemed  to  be  more  pronounced  in 
neurotics  and  old  alcoholics. 


THE   USE    OF   MORPHIN   AND    SCOPOLAMIN 

Pantopon  (pant  opium)  introduced  by  Sahli,  of  Berne,  in  1909,  is 
now  occupying  much  attention,  owing  to  the  therapeutic  advantages 
claimed  for  it.  It  consists  essentially  of  a  mixture  of  the  combined 
alkaloids  of  crude  opium,  said  to  exist  in  a  definite  stable  solution 
in  the  form  of  chlorids  in  a  fairly  constant  proportion — viz.,  morphin, 
narcotin,  codein,  papaverin,  narcein,  thebein,  hydrocotarnin,  coda- 
min,  laudanin,  laudanidin,  laudanoein,  miconidin,  papaveramin,  pro- 
topin,  lanthopin,  cryptopin,  gascopin,  oxynarcodin,  xanthalin,  and 
tritopin.  It  is  obtained  as  a  yellowish-brown  amorphous  powder 
resembling  powdered  opium,  easily  soluble  in  water,  less  so  in  alcohol. 
Pantopon  is  particularly  recommended  for  administration  before 
general  anesthetics,  but  it  may  be,  if  it  fulfill  the  claims  made  for  it, 
that  it  may  largely  supersede  morphin  in  a  more  general  use ;  further, 
the  use  of  such  multiple  combinations  of  alkaloids  as  exist  in  pantopon 
bear  out  Burgi's  contention. 

The  dose  of  pantopon  is  given  as  slightly  greater  than  that  of 
morphin,  0.3  gr.  of  pantopon  equalling  0.25  gr.  of  morphin.  The 
anodyne  effect  is  very  marked,  the  pulse  is  slow  and  regular,  the 
respirations  are  quiet,  regular,  and  deeper  than  after  morphin,  and 
their  frequency  but  slightly  less  than  normal;  in  other  respects  its 
action  is  very  similar  to  that  of  morphin.  Due  to  its  very  slight 
action  upon  the  respiratory  frequency  and  depth,  it  has  been  par- 
ticularly recommended  for  administration  before  general  anesthetics, 
but  these  advantages  are  not  of  much  value  to  us  here.  Other  ad- 
vantages claimed  for  this  drug  are  that  the  after-nausea  and  other 
unpleasant  disturbances  are  much  less  than  after  morphin. 

Representing  as  it  does  all  the  alkaloids  in  the  same  proportion  as 
they  exist  in  the  gum,  its  action  is  the  same  as  that  of  opium.  It  is 
more  narcotic,  soporific  and  sedative  than  morphin  but  in  propor- 
tionate doses  exerts  less  control  over  pain.  In  many  nervous  or 
neurotic  subjects,  when  morphin  excites  and  produces  insomnia 
without  relieving  pain  pantopon  will  be  found  to  exert  an  opposite 
effect.  As  a  preliminary  to  major  operations  under  local  anesthesia, 
I  much  prefer  it  to  morphin,  usually  using  it  alone  in  from  Y§-  to 
3^-gr.  doses,  depending  upon  the  type  of  individual  and  the  nature 
of  the  operation.  It  combines  well  with  scopolamin,  and  when 
used  in  this  way  the  dose  of  the  latter  need  not  exceed  3-fso  gr. 
The  combination  tends  to  eventually  increase  the  sedative  and  sopo- 
rific action  of  each.  In  the  last  few  years  I  have  used  it  to  the 
practical  exclusion  of  morphin. 


1 98  LOCAL   ANESTHESIA 

COMBINED  METHODS  OF  ANESTHESIA 

While  in  the  preceding  remarks  the  use  of  morphin  or  pantopon 
and  scopolamin  are  not  used  for  their  anesthetic  effect,  they  un- 
doubtedly exert  some  influence  in  that  direction  by  acting  as  cere- 
bral anodynes,  and  may  often  contribute,  when  in  combination  with 
local  anesthetics  and  the  light  superficial  use  of  general  anesthetics, 
to  accomplish  safely  a  delicate  surgical  procedure. 

"By  utilizing  the  anesthetic  properties  of  cocain  and  other  local 
anesthetics  (including  ethyl  chlorid,  Bloch)  with  morphin,  a  pre- 
liminary stage  of  diminished  sensibility  is  produced,  which  is  also 
most  favorable  to  the  action  of  general  anesthesia.  An  important 
group  of  major  operations  which  cannot  be  undertaken  with  local 
anesthesia  alone,  and  in  which  the  condition  of  the  patient  centra- 
indicates  chloroform  or  ether,  can  be  painlessly  performed  with  the 
aid  of  a  very  superficial,  intermittent,  and  purely  cortical  anesthesia 
(Morphin-cocain  -ether  Anesthesia) ." 

In  this  method  the  essential  point  is  also  to  subdue  the  sensi- 
bility of  the  skin  as  a  preliminary;  after  this  is  accomplished  very 
little  general  anesthetic  will  be  required  to  complete  the  operative 
work  in  the  deeper  tissues.  No  saturation  with  ether,  as  a  rule,  will 
be  needed,  and  in  this  way  the  dangerous  effects  of  the  drug  will  be 
avoided  or  will  be  reduced  to  a  remarkably  safe  minimum.  (See  O. 
Bloch,  loc.  cit. ;  Schleich,  loc.  cit.,  and  H.  Gushing,  "Annals  of  Surg.," 
January,  1900).  (Matas.)  This  idea  put  into  actual  practice  as  a 
routine  is  the  essential  feature  in  the  Anoci  method  of  Crile. 

Such  conditions  may  arise  in  the  badly  septic  or  marasmic  patient 
—nephritic,  diabetic,  endocarditic,  and  other  constitutional  states — 
where  surgical  relief  seems  imperative  yet  inadvisable  by  any  single 
means  alone,  as  when  such  patients  are  suffering  from  appendicitis 
with  an  adherent,  embedded,  or  retrocecal  appendix,  or  from  a  chole- 
cystitis with  a  difficultly  accessible  gall-bladder,  ectopic  gestation, 
etc. 

In  such  cases  the  combination  of  all  methods  may  prove  ad- 
visable, making  use  of  a  morphin-scopolamin-cocain-ether,  chloro- 
form or  nitrous  oxide  anesthesia.  If  the  field  of  operation  is  so 
situated  that  spinal  anesthesia  will  prove  effective  this  should,  of 
course,  be  given  consideration,  but  often  this  will  not  be  advisable  or 
suited  to  the  case.  Under  such  conditions,  with  the  patient  quieted 
with  a  preliminary  hypodermic,  the  peripheral  or  easily  accessible 
parts  are  anesthetized  by  local  or  regional  measures,  advancing  as 


THE   USE    OF   MORPHIN   AND   SCOPOLAMIN  1 99 

far  as  possible  by  these  means  to  the  seat  of  trouble ;  then  a  few  whiffs 
of  a  general  anesthetic,  sufficient  only  for  a  purely  cortical  anesthesia, 
inducing  at  most  a  subconscious  state,  in  which  pain  alone  is  arrested 
but  memory  and  the  other  senses  are  often  retained,  and  thus  enable 
the  operator  to  execute  the  deeper  parts  of  the  work  without  pain. 
The  patient  is  allowed  to  recover  as  soon  as  this  is  accomplished, 
when  the  closing  steps  of  the  operation  are  completed  by  local  meas- 
ures. While  conditions  justifying  combinations  of  this  kind  do  not 
often  occur,  they  are  occasionally  met  with,  and  can  often  be  more 
safely  handled  by  combined  measures  than  by  any  single  method 
used  alone. 

On  the  other  hand,  one  may  often  undertake  intra-abdominal 
operations  by  local  anesthesia,  and,  once  within  the  abdomen,  en- 
counter unexpected  difficulties  by  meeting  more  extensive  pathology 
or  complicated  conditions  not  anticipated,  and  be  forced  to  resort 
to  a  general  anesthetic  to  perform  the  more  difficult  parts  of  the 
operation,  withdrawing  the  general  anesthetic  when  this  is  completed. 

In  the  above  connection  we  may  call  attention  to  the  intra- 
abdominal  action  of  urea  and  quinin  hydrochlorid,  as  spoken  of  by 
Dr.  Thibault  in  the  chapter  on  Quinin,  but  which  we  have  not  so  far 
had  occasion  to  use  in  this  way. 

Another  class  of  patients  where  combined  methods  of  anesthesia 
may  prove  highly  useful  is  in  operation  upon  the  neurotic,  emo- 
tional, or  highly  sensitive  individual,  where,  owing  to  centra-indica- 
tions, it  is  inadvisable  to  operate  by  general  anesthesia.  Resort  can 
often  be  had  to  purely  cortical  anesthesia  while  performing  the  opera- 
tion painlessly  under  local  methods,  thus  preventing  both  the  psychic 
influences  in  their  production  of  shock  as  well  as  all  reflexes  from 
the  field  of  operation. 

Psychic  impressions  bear  no  small  part  in  the  production  of  shock, 
and  reflexes  thus  excited  from  the  brain  may  affect  the  vital  centers 
just  as  seriously  as  the  effects  of  trauma  at  the  periphery. 

Crile  has  always  insisted  on  this  element  in  the  production  of 
shock,  and  the  published  results  of  his  experiments  show  clearly  that 
definite  demonstrable  changes  occur  in  the  cells  of  the  brain  as  the 
result  of  fear.  He  has  amply  shown  that  trauma,  anemia,  infection, 
and  fear  produce  not  only  very  definite  symptoms,  but  that  singly  or 
in  combination  may  damage  the  brain-cells,  and  so  influence  the 
immediate  results  of  surgical  operations.  (See  chapter  on  Anoci- 
association.) 

The  idea  and  advantages  of  combining  spinal  analgesia  with  a 


200  LOCAL    ANESTHESIA 

light  superficial  ether  narcosis,  sufficient  to  prevent  the  shock  from 
psychic  impressions,  has  been  advocated  by  some  writers,  but  the 
advantages  of  such  combinations  do  not  appear  very  apparent  ex- 
cept that  the  stimulation  of  the  ether  may  help  to  support  the  blood- 
pressure. 

Combined  methods  of  anesthesia  may  often  be  advantageously 
utilized  by  the  surgeon  specialist,  as  in  operations  upon  children  or 
highly  nervous  patients  for  affections  about  the  nose  and  throat; 
here  all  that  is  necessary  is  to  keep  the  patient  asleep,  using  a  very 
superficial  anesthesia,  which  can  often  be  administered  in  a  semi- 
recumbent  position,  ether  being  preferred;  the  anesthesia  of  the  part 
is  secured  in  the  usual  way  by  the  local  use  of  cocain;  as  the  field  of 
operation  is  blocked  by  the  use  of  the  local  anesthetic,  shock  is  often 
less  than  when  operating  by  general  anesthesia  alone. 

The  rationality  for  the  use  of  combinations  such  as  morphin- 
scopolamin  or  cocain-ether  is  amply  explained  by  Burgi's  contention, 
and  if  this  contention  is  correct,  and  it  seems  to  have  been  amply 
demonstrated,  we  can  readily  understand  how  the  skilful  use  of  small 
quantities  of  each  agent,  each  too  small  to  exert  any  possible  in- 
jurious action  alone,  often  enables  one  to  accomplish  absolutely 
painlessly  and  safely  operations  of  considerable  magnitude. 

As  just  stated,  it  will  probably  be  seen,  on  further  thought, 
that  all  four  agents  are  actually  more  synergistic  than  might  ap- 
pear. It  will  be  readily  conceded  that  opiates,  scopolamin,  and 
ether  (or  chloroform)  enhance  the  central  action  of  each  other  and 
prepare  these  centers  for  the  maximum  benefit  to  be  derived  from 
the  use  of  local  anesthetics.  While  not  of  practical  value  it  has  been 
amply  demonstrated  that  cocain  exerts  a  well-marked  central  action 
as  well  as  local.  For  a  confirmation  of  this  statement  we  refer  to 
the  abdominal  experiments  of  Kast  and  Meltzer,  spoken  of  in  the 
opening  part  of  the  chapter  on  Abdominal  Surgery;  also  to  general 
anesthesia  by  cocain,  as  proved  by  Harrison's  and  Hitter's  experi- 
ments, and  cited  under  General  Anesthesia  with  Cocain. 


CHAPTER  X 
INDICATIONS,  CONTRA-INDICATIONS,  AND  SHOCK 

INDICATIONS  AND  CONTRA-INDICATIONS 

IT  has  been  said  that  the  advantages  of  operation  under  local 
anesthesia  are  entirely  with  the  patient;  this  is  so  in  so  far  as  life  is 
concerned,  but  the  surgeon  too  often  shares  in  the  benefits  that  arise 
from  this  method  of  operation,  his  aim  being  always  to  relieve  suffer- 
ing and  save  the  life  of  the  patient;  the  reduction  of  his  mortality 
by  safely  tiding  an  operative  case  through  the  many  dangers  which 
threaten  must,  indeed,  be  a  source  of  great  satisfaction  to  the  con- 
scientious operator.  The  special  advantages  offered  to  the  comfort 
of  the  patient  are  the  absence  of  the  disturbances  incident  to  general 
anesthesia.  The  fear  of  general  anesthesia  entertained  by  many 
people,  especially  if  they  have  had  one  experience  and  suffered  much 
from  postoperative  nausea,  will  often  deter  them  from  subsequent 
operative  treatment  unless  imperative. 

The  distinct  advantages  in  addition  to  those  of  relief  from  fear 
are: 

It  is  unnecessary  to  starve  the  patient  beforehand.  The  alimen- 
tary canal  should,  however,  be  well  emptied  by  a  suitable  cathartic, 
and  a  light  nutritious  meal  given  at  the  regular  .meal  time  preceding 
the  operation.  All  patients  stand  local  anesthetics  better  when  fed 
beforehand,  and  it  is  a  distinct  advantage  in  preventing  weakness  or 
shock  in  debilitated  subjects. 

There  is  no  postanesthetic  disturbance  to  the  alimentary  canal, 
which  is  often  so  trying  to  both  patient  and  physician,  such  as  the 
vomiting  and  straining  accompanying  the  act,  causing  both  pain  and 
frequently,  when  severe  or  prolonged,  jeopardizing  the  results  of  the 
work  when  this  has  been  about  the  face,  mouth,  or  abdominal  walls. 

The  possibility  of  dilatation  of  the  stomach  and  intestinal  paresis 
or  tympanites  is  eliminated. 

The  regular  postoperative  nourishment  is  not  interfered  with, 
this  is  of  great  importance  in  weakened  individuals,  and  permits  a 
more  rapid  recovery  and  convalescence  from  the  operative  proce- 
dure. Many  weakened  subjects  may  survive  the  operation,  but  die 
from  exhaustion  due  to  interruption  of  nutrition  as  the  result  of  a 
disturbed  alimentary  canal. 

201 


202  LOCAL   ANESTHESIA 

The  pain  in  the  back  so  many  suffer  from  after  prolonged  general 
anesthesia,  due  to  complete  relaxation  of  all  ligamentous  supports 
to  the  vertebral  column,  permitting  sagging  of  the  lumbar  curve 
with  necessary  strain,  is  avoided. 

General  anesthesia  is  particularly  dangerous  to  the  cachectic, 
the  feeble,  aged,  arteriosclerotic,  those  suffering  from  advanced 
cardiac,  pulmonary,  renal  and  hepatic  disease,  in  alcoholics,  as  well 
as  in  many  other  conditions,  such  as  shock,  to  be  mentioned  later. 

Chloroform  is  particularly  dangerous  in  all  cases  of  septic  infec- 
tion. It  may  be  argued  that  in  some  of  the  above-mentioned  condi- 
tions local  anesthesia  may  present  certain  dangers;  this  may  be  true 
in  some  few  cases,  but  the  danger  is  always  less  than  that  of  general 
anesthesia. 

Local  anesthesia  seems  actually  contra-indicated  in  very  few 
conditions,  among  which  may  be  mentioned  children,  epileptics, 
highly  nervous  or  neurotic  subjects;  there  are  actually  very  few 
pathologic  conditions  in  which  local  anesthesia  is  not  safer  than 
general. 

The  additional  trauma  suffered  by  the  tissues,  due  to  the  infiltra- 
tions, might  in  some  few  cases  of  low  vitality  be  regarded  as  a  disad- 
vantage, but  it  is  in  just  such  cases  of  low  vitality  that  general  anes- 
thesia is  more  dangerous. 

SHOCK 

Shock  when  severe  is  a  condition  in  which  general  anesthesia  is 
contra-indicated;  the  administration  of  a  general  anesthetic  does  not 
necessarily  relieve  the  reflexes  to  the  higher  centers,  and  when  this 
condition  is  marked  may  prove  highly  dangerous,  and  should  not  be 
used  when  it  is  possible  to  employ  local,  regional,  or  even  spinal  anes- 
thesia, which  block  the  afferent  nerve-paths  and  prevent  further  im- 
pressions being  recorded  at  the  higher  centers. 

Dr.  Crile's  studies,  demonstrations,  and  brilliant  presentation  of 
this  subject  has  elucidated  many  points  previously  but  imperfectly 
understood.  In  the  Brit.  Med.  Jour,  of  September  17,  1910,  on  the 
"Prevention  and  Treatment  of  Shock,"  he  writes  as  follows: 

"It  is  well  also  to  bear  in  mind  that  in  inhalation  anesthesia 
only  a  part  of  the  brain  is  asleep.  Complete  anesthesia  of  the  brain 
produces  suspended  animation  or  death.  The  medulla  at  least  is  but 
little  affected,  and  the  response  of  the  unanesthetized  portion  of  the 
brain  is  constantly  observed  in  the  course  of  operations;  for  example, 
the  altered  rate  and  rhythm  of  the  pulse  and  respiration,  the  change  in 


INDICATIONS,    CONTRA-INDICATIONS,   AND    SHOCK  203 

the  vasomotor  tone,  as  indicated  by  the  fluctuation  in  the  blood- 
pressure,  the  contraction  of  muscles,  and,  under  light  anesthesia, 
purposeless  movements  of  the  body,  all  show  that  a  large  portion  of 
the  brain  is  either  partially  or  not  at  all  anesthetized.  These  sub- 
conscious phenomena  represent  the  discharge  of  nervous  energy  in 
response  to  mechanical  stimulation  of  the  nociceptors,  and  are  vain, 
subconscious  efforts  of  defense  or  escape.  The  greater  such  sub- 
conscious action,  the  greater  the  shock.  In  bad  risks  the  subcon- 
scious response  should,  if  possible,  be  wholly  excluded  by  the  com- 
bination of  local  with  general  anesthesia,  the  local  anesthesia  phys- 
ically blocking  the  afferent  impulses,  thus  sequestering  the  brain  from 
harmful  impulses." 

In  operations  upon  the  larynx  the  reflex  inhibitory  impulses 
should  be  prevented  by  the  local  application  of  cocain. 

In  all  operations  where  the  impressions  from  the  field  of  operation 
may  favor  the  development  of  shock,  local  anesthesia  should  be  com- 
bined with  general;  this  also  lessens  the  necessity  of  profound 
general  anesthesia.  Also  spoken  of  under  the  heading  of  Combined 
Methods  of  Anesthesia. 

Whenever  in  the  course  of  an  operation  large  nerve-trunks  are 
to  be  divided,  and  the  possible  effects  of  shock  are  to  be  avoided,  as  in 
the  division  of  the  sciatic  branches  of  .the  brachial  plexus,  etc.,  the 
nerves  should  first  be  injected  with  an  anesthetic  solution  before 
division. 

In  the  presence  of  marked  shock,  spinal  anesthesia  should  never 
be  used  as  it  further  lowers  the  blood-pressure,  but  in  all  injuries  to 
the  extremities  where  the  nerve-trunks  are  readily  accessible,  opera- 
tion may  be  indicated,  even  in  profound  shock,  unless  the  patient 
is  moribund;  as  reaching  and  blocking  the  nerve- trunks  arrests  fur- 
ther impressions  from  the  periphery  and  may  permit  the  more  ready 
recovery  of  the  patient,  providing  same  can  be  done  without  too 
much  manipulation.  While  shock  under  strictly  local  methods  of 
procedure  is  often  negligible  or  reduced  to  a  minimum,  it  does  never- 
theless occasionally  occur  in  depressed  or  weakened  individuals, 
particularly  in  extensive  operations  involving  the  visceral  cavities, 
and  this  may  occur  without  the  least  pain  having  been  inflicted ;  but 
while  it  is  always  markedly  less  than  under  any  method  of  general 
anesthesia,  it  must  occasionally  be  reckoned  with  as  a  possibility. 


CHAPTER  XI 
ANOCI-ASSOCIATION 

A  NEW  interest  and  importance  has  been  given  to  local  anesthesia 
by  the  recent  work  of  Crile  on  "  Anoci-association."  This  principle, 
founded  on  sound  physiological  grounds  and  well  tested  clinically,  is 
the  gradual  evolution  and  outgrowth  of  the  Morphin-cocain-ether 
anesthesia  advocated  in  the  earlier  days  of  cocain  by  Block,  Schleich, 
Matas,  Gushing  and  Crile.  Crile's  early  work,  as  a  pioneer  in  local 
anesthesia,  had  done  much  to  advance  the  art  and  help  place  it  upon 
a  firm  and  scientific  foundation,  and  now  by  reviving,  amplifying 
and  perfecting  this  method  he  has  shown  the  general  surgeon  its 
many  hitherto  unrecognized  advantages. 

Trauma,  hemorrhage,  and  psychic  influences  are  the  three  great 
shock  producers.  The  effects  of  trauma  may  be  either  conscious  or 
unconscious  (as  when  under  an  anesthetic) . 

Crile  compares  the  nerves,  whether  of  special  sense  or  common 
sensation,  to  fuses,  which  when  stimulated  cause  a  release  of  energy 
in  the  magazine  (the  brain-cells). 

In  inhalation  anesthesia  only  a  part  of  the  brain  is  asleep;  if  the 
entire  brain  were  anesthetised  it  would  produce  death.  The  purpose- 
less movements  of  a  patient  under  an  anesthetic  are  efforts  for  defense 
or  escape,  and  represent  so  much  discharge  of  energy.  Muscular  con- 
tractions under  operation,  the  quickened  heart-beat,  or  disturbed 
rhythm  of  respiration,  all  represent  reflexes  arising  from  the  field 
of  operation  and  producing  their  impression  on  the  brain-cells. 

During  fear  or  other  psychic  strain  tremendous  energy  is  given 
off;  if  continued,  leading  to  exhaustion  and  shock.  We  do  not  pos- 
sess a  single  anesthetic  capable  of  protecting  the  brain  during  opera- 
tion from  harmful  stimuli  or  reflexes.  General  anesthetics  prevent 
the  psychic  stimuli;  local  anesthetics  block  the  nerve-paths  and  pre- 
vent traumatic  reflexes;  the  combination  furnishes  the  ideal. 

In  children  and  nervous  individuals  who  enter  the  operating  room 
in  fear  and  trembling,  the  above  combination  is  undoubtedly  the  best. 
Too  little  attention  has  been  paid  in  the  past  to  these  psychic  influ- 
ences and  the  effect  of  trauma  under  anesthetics,  and  it  is  in  prevent- 
ing these  nocuous  influences  that  much  improvement  can  be  attained 

204 


ANOCI-ASSOCIATION  205 

in  the  future.  In  the  stout  and  robust,  who  have  energy  to  spare, 
this  may  not  be  so  apparent,  but  few  of  our  patients  are  from  this 
class;  many  are  already  reduced  by  the  condition  which  brings  them 
to  surgeons.  We  too  often  see  patients  requiring  weeks  or  months  to 
regain  their  health  following  an  ordinary  operation,  their  depression 
being  out  of  all  apparent  proportion  to  the  operation  and  coincident 
confinement  in  bed,  or  we  see  the  neurotic  or  neurasthenic  made  worse 
by  the  procedure  which  was  intended  to  improve. 

In  these  cases  too  little  attention  has  been  paid  to,  and  no  provi- 
sions made  for,  the  psychic  strain  and  trauma  under  anesthetics, 
which  persists  from  the  incised  and  traumatised  parts  until  healing 
has  taken  place. 

It  is  along  these  lines  that  improvement  must  come  in  our  opera- 
tive surgery  of  the  immediate  future.  Improvements  will  come  in 
our  operative  technic,  but  the  fundamental  principles  underlying 
the  commonly  performed  operations  of  to-day  are  not  likely  to  suffer 
any  radical  change,  at  least  with  the  present  conception  of  surgical 
principles.  But  improvements  can  come,  and  are  within  reach  of  us 
all,  for  the  operative  handling  of  our  cases. 

Children  and  highly  nervous  individuals  should  not  be  oper- 
ated on  by  purely  local  methods  alone,  but  by  combinations  of 
local  with  opiates  or  general,  and  if  a  general  anesthetic  is  needed  it 
need  not  be  pushed  to  the  point  of  profound  narcosis,  but  only  suffi- 
ciently deep  to  prevent  psychic  and  cortical  reflexes.  By  this  plan 
we  will  have  accomplished  the  ideal  for  these  patients  by  removing 
the  dangers  of  profound  narcosis,  and  favor  a  pleasanter  and  more 
rapid  and  complete  recovery  by  removing  all  elements  of  shock. 

In  the  average  individuals  who  make  up  the  great  majority  of  our 
patients,  when  suffering  with  conditions  favorable  for  operation 
under  purely  local  or  regional  methods  of  anesthesia,  the  general 
anesthetic  can  be  entirely  dispensed  with,  and  the  psychic  influences 
controlled  by  a  preliminary  hypodermic  of  morphin,  %  gr.,  or  pan- 
topon  Y±  gr.,  with  scopolamin  ^f50  gr.;  this  produces  a  somnolent, 
indifferent  frame  of  mind  quite  favorable  for  any  operative  under- 
taking; when,  if  our  technic  is  perfect  and  no  pain  inflicted,  we  have 
accomplished  the  ideal  for  this  class  of  patients  which  make  up  our 
great  majority,  and  no  major  operation  should  be  performed  under 
local  anesthesia  without  this  preliminary  hypodermic. 

See  Chapter  IX  for  a  discussion  of  the  benefits  of  opiates. 

Dr.  Crile,  in  employing  his  anoci  principle,  begins  the  injection 
of  the  local  anesthetic  after  the  patient  is  unconscious  from  the  gen- 


206 


LOCAL   ANESTHESIA 


eral  anesthetic;  he  prefers  to  use  0.5  per  cent,  quinin  and  urea  for 
blocking  purposes,  and  the  technic  is  the  same  as  if  the  operation 
was  to  be  performed  under  purely  local  methods  alone,  infiltrating 
or  blocking  all  regions;  consequently  the  methods  described  in  this 
book  can  be  followed.  We,  however,  feel  some  hesitation  in  using 
quinin  and  urea  too  extensively  and  in  all  tissues  for  this  purpose; 
while  it  does  produce  a  lasting  analgesia  for  several  days  to  a  week,  its 
objectionable  quality  of  often  producing  massi  fibrinous  exudates 
in  the  infiltrated  area,  with  an  occasional  tendency  to  suppuration, 


Fig.  22. — Anoci-association  diagram:  i,  Auditory,  visual,  olfactory,  and  traumatic 
noci  impulses  reaching  the  brain;  2,  auditory,  visual,  olfactory  associations  excluded; 
3,  nerve  blocked  by  cocain;  patient  in  anoci-association.  (After  Crile.) 

must  not  be  lost  sight  of,  as  pointed  out  in  the  chapter  dealing  with 
this  subject.  We  consequently  prefer  to  use  throughout  either  0.25 
or  0.5  per  cent,  novocain  with  adrenalin,  even  though  its  effect  may 
not  last  much  beyond  the  time  consumed  in  the  operation.  As  the  re- 
sults obtained  by  Dr.  Crile  with  quinine  and  urea  cannot  differ  essen- 
tially from  the  results  obtained  following  our  own  use  of  this  drug,  I 
look  forward  to  the  time  when  Crile  also  will  abandon  this  agent. 
The  employment  of  the  anoci  principle  is  graphically  illustrated  in 
Fig.  22,  taken  from  Crile.  Figures  23  and  24,  taken  from  the  same 
author,  show  in  a  striking  way  the  effects  of  shock  and  fear  upon  the 


ANOCI-ASSOCIATION  207 

Normal  dog.  Anoci  shocked  dog.     Cerv.  cord  severed. 


Shocked  dog.         Ether  anesthesia. 


Normal  rabbit. 


Shocked  dog.     NaO  anesthesia. 
Fig.  23.  (From  Crile.) 

Rabbit.     Fright. 


)& 


m 


r* 


*#  « 


* 
. 


Rabbit  two  hours  after  fright. 


Characteristic  changes  Characteristic  changes 

in  brain   cells  in  fright,  in  brain  cells  in  shock. 

Hyperchromatic  during  Note  swelling  and  rup- 

fright.    Exhausted  after  ture  of  nucleus  and  nist- 

fright.  bodies. 

Fig.  24.  (From  Crile.) 


208 


LOCAL   ANESTHESIA 


brain-cells  of  animals.  Figures  25  and  26  show  the  comparative 
results  obtained  by  different  methods  of  anesthesia,  and  illustrate 
very  forcibly  the  advantages  of  the  anoci  principle.  This  latter 


tDe?TC«s 

38 

33 

100 

101 

102 

103 

Ether 

NxO. 

A^oci 

Bea-ts 

70 

80 

90 

100 

110 

120 

Ether, 

NiO. 

A*oei 

Fig.  25. — Abdominal  hysterectomy.  The  temperature:  Each  heavy  line  represents 
the  average  5.00  P.M.  temperature  of  10  patients  during  the  first  four  days  after  oper- 
ation. The  pulse:  Each  heavy  line  represents  the  average  5.00  P.  M.  pulse  rate  of  10 
patients  during  the  first  four  days  after  operation.  (From  Crile.) 

work  of  Crile  is  bound  to  add  a  great  impetus  to  local  anesthesia, 
whether  we  employ  it  in  association  with  light  cortical  general  anes- 


Degrees 

38 

33 

100 

101 

102 

103 

Ether 

N*0. 

A-noCi 

Be*t» 

70 

80 

90 

100 

110 

I20J 

Ether 

NaO 

Atiecl, 

Fig.  26. — Thyroidectomy.  The  temperature:  Each  heavy  line  represents  the  aver- 
age 5.00  P.  M.  temperature  of  10  patients  during  the  first  four  days  after  operation. 
The  pulse:  Each  heavy  line  represents  the  average  5.00  P.  M.  pulse  rate  of  10  patients 
during  the  first  four  days  after  operation.  (After  Crile.) 

thesia  or  the  preliminary  hypodermic  of  morphin  and  scopolamin, 
or  both. 

The  survival  or  failure  of  any  method  advocated  for  practical 
daily  use  must  rest  entirely  upon  the  clinical  results  obtained.     The 


ANOCI-ASSOCIATION  2OQ 

prime  object  of  all  surgery,  as  well  as  all  medicine,  is  the  relief  of  suffer- 
ing and  the  prolongation  of  life;  those  measures  which  attain  these 
ends  with  the  least  disturbance  to  the  patient  and  the  least  suffering 
must  ultimately  prevail  to  the  exclusion  of  all  other  harsher  and  less 
agreeable  methods. 

Here  local  anesthesia  in  its  anoci  features,  as  applied  to  major 
operations,  has  a  decided  claim  in  offering  to  the  patient  a  pleasanter 
convalescence. 

How  often  one  hears  the  complaint  from  a  patient  disturbed  by 
a  persistent  postanesthetic  nausea,  or  racked  by  gas  pains  following 
a  laparotomy :  "  Oh,  doctor,  if  I  had  known  what  I  had  to  go  through 
I  would  never  have  consented."  Compare  this  picture  with  a  similar 
case  operated  by  local  anesthesia  and  note  the  contrast;  the  great 
nightmare  of  ether,  with  its  resulting  nausea  is  removed,  and  the 
entire  absence  or  reduction  to  a  minimum  of  postoperative  gas  pains 
in  abdominal  operations,  or  lessened  painful  reaction  in  other  wounds 
produces  a  pleasanter,  easier,  less  dreaded  convalescence,  with  prac- 
tically no  disturbance  of  the  nervous  equilibrium.  There  are  no  ex- 
hausting demands  for  unnecessary  and  wasted  energy  upon  the  cen- 
tral nervous  system,  less  constant  and  exacting  attention  on  the 
part  of  nurses  and  doctors  afterward,  less  use  of  the  stomach-tube, 
and  less  of  hot  stupes  and  high  rectal  flushes.  These  are  the  ad- 
vantages offered  by  local  anesthesia.  Crile  states  that  90  per  cent, 
of  his  cases  operated  by  the  anoci  principle  have  no  unpleasant  rec- 
ollection of  the  day  of  their  operation.  How  can  we  explain  the 
differences? 

First,  The  absence  of  a  general  anesthetic,  or  its  superficial  use 
for  purely  cortical  anesthesia,  removes  the  postanesthetic  nausea. 
This  is  in  itself  a  decidedly  disturbing  factor  in  its  constant  retching 
and  efforts  at  vomiting  in  disturbing  the  field  of  operation,  particu- 
larly so  if  it  is  abdominal,  lighting  up  with  each  effort  new  pains  by 
the  tug  and  pull  on  the  incised  and  sutured  parts,  requiring  for  relief 
repeated  hypodermics  of  morphin,  which  often  aggravate  the  nausea. 

Second,  The  blocking  process  by  the  local  anesthesia  in  the  field 
of  operation  absolutely  prevents  all  reflexes  from  reaching  the  sur- 
rounding parts  as  well  as  centrally,  consequently  there  is  less  dis- 
turbance of  normal  equilibrium  and  less  after-reaction,  and  if  the 
wound  has  been  handled  without  undue  trauma,  by  the  time  the 
operation  is  completed  and  the  anesthesia  subsides  a  slight  soreness 
is  all  that  is  complained  of. 

The  final  proof  must  then  come  in  the  clinical  use  of  these  meas- 
14 


2IO  LOCAL    ANESTHESIA 

• 

ures,  and  this  proof  I  feel  has  been  already  amply  furnished  by  the" 
pioneer  workers  in  this  field  and  to  be  now  past  the  experimental 
stage  and  beyond  all  controversy.  I  have  often  seen  cases  operated 
for  serious  abdominal  conditions  practically  free  from  postoperative 
disturbance  and  hard  to  convince  that  they  had  gone  through  a  severe 
major  operation. 

In  this,  the  physiological  era  of  surgery  we  are  striving  for  the 
ideal — shockless  surgery.  We  may  never  attain  it  but  we  hope  to 
approach  it.  All  surgery  of  the  future  must  embody  the  anoci  prin- 
ciples in  their  broadest  sense.  The  patient  must  be  protected  from 
all  physical  and  psychical  disturbances  which  it  is  possible  to  remove, 
and  only  then  have  we  done  our  best.  The  method  as  employed  by 
Crile  to-day  must  undergo  a  change,  as  it  has  its  defects,  but  the 
principle  is  eminently  correct;  but  no  man  can  apply  those  principles 
who  cannot  first  operate  under  local  alone  without  the  aid  of  general 
anesthesia.  A  few  purposeless  injections  into  an  anesthetized  patient 
who  cannot  remonstrate  is  not  anoci.  Local  anesthesia  is  the  foun- 
dation of  anoci  and  these  principles  must  come  first  with  those  who 
practice  this  method  as  taught  to-day. 


CHAPTER  XII 
INTRA-ARTERIAL  ANESTHESIA 

THE  first  records  we  have  of  the  injection  of  cocain  into  arteries 
was  with  a  view  of  determining  its  toxicity  when  administered  in 
this  manner. 

Alms  in  1886  was  the  first  to  report  its  anesthetizing  effect  in  the 
field  supplied  by  the  artery;  he  experimented  by  injecting  cocain 
into  the  iliac  artery  of  the  frog,  in  this  way  carrying  it  to  the  entire 
distribution  of  this  vessel  in  the  lower  limb,  bringing  about  complete 
motor  and  sensory  paralysis. 

Since  the  introduction  of  Bier's  intravenous  anesthesia,  investiga- 
tors began  to  consider  the  arterial  route  as  a  means  of  diffusing  anes- 
thetic solutions  for  surgical  purposes.  The  method  was  first  used 
by  Oppel  and  Goyanes,  who  injected  weak  solutions  of  cocain  into 
arteries  between  two  constrictors;  their  results  were  quite  interesting, 
but  not  of  much  value  clinically. 

The  method  has,  however,  recently  been  brought  forward  by 
several  operators  working  along  slightly  different  lines. 

Terminal  arterial  anesthesia  has  been  introduced  by  Ransohoff, 
of  Cincinnati,  who  reported  his  results  in  the  "Lancet-Clinic,"  1909, 
and  later,  in  a  more  thorough  article,  in  the  "Annals  of  Surgery," 
1910.  The  following  is  from  Prof.  Ransohoff's  report: 

"  CASE  I. — Male,  aged  seventy-two,  in  the  service  of  Dr.  Robert  Carothers,  through 
whose  courtesy  I  am  enabled  to  report  this  case.  The  patient  had  been  suffering  for 
three  years  from  a  chronic  osteomyelitis  of  the  hand,  which  became  so  painful  as  to 
necessitate  an  amputation.  His  age  and  condition  contra-indicated  general  anesthesia. 
Operation  at  Good  Samaritan  Hospital,  July  12,  1909.  An  Esmarch  bandage  was 
applied  about  the  arm  2  inches  below  the  insertion  of  the  deltoid.  Under  infiltration 
anesthesia  the  brachial  artery  was  exposed  and  the  needle  of  a  hypodermic  syringe 
inserted  into  its  lumen,  and  i  c.c.  of  a  2  per  cent,  cocain  solution  injected  into  the  artery 
in  the  direction  of  the  blood-current.  In  two  minutes  anesthesia  was  absolute  and 
antibrachial  amputation  done  without  the  patient's  knowledge. 

"There  are  two  features  of  special  interest  in  this  case — the  rapidity  of  anesthesia 
and  the  fact  that  the  operation  was  performed  without  the  patient's  knowledge.  After 
the  operation  had  been  completed  the  patient  asked  when  we  would  begin.  This 
absolute  anesthesia  is  a  salient  feature  of  this  method,  as  well  as  one  of  its  greatest 
advantages. 

"CASE  II. — Female,  aged  fifty,  service  of  Dr.  Robert  Carothers,  Cincinnati  Hospital. 
Diagnosis :  Osteoma  of  scaphoid  bone.  Operation:  Esmarch  strap  applied  tightly  above 
knee.  Under  infiltration  anesthesia  the  anterior  tibial  artery  was  exposed  just  above 


212  LOCAL   ANESTHESIA 

the  ankle  and  i  c.c.  of  i  per  cent,  cocain  solution  injected  into  the  artery.  This 
was  immediately  followed  by  complete  anesthesia  of  the  entire  foot,  during  which 
the  osteoma  was  removed  without  the  patient  suffering  the  slightest  pain.  The 
further  history  was  uneventful. 

"A  series  of  animal  experiments  was  now  done  to  determine  the 
certainty  of  anesthesia,  its  safety,  and  its  applicability  in  operations 
other  than  amputations.  In  all,  ten  experiments  were  done — the 
first  series  in  rabbits,  the  second  in  dogs.  It  will  be  seen  that  in 
operations  other  than  amputations  a  2  per  cent,  cocain  solution  is 
too  strong  to  be  consistent  with  safety,  because  of  the  danger  of 
absorption  into  the  general  circulation.  A  0.5  per  cent,  cocain  solu- 
tion was  used  and  found  in  every  way  adequate. 

"In  the  experiments  on  rabbits  the  femoral  artery  was  selected 
as  the  site  of  injection.  The  artery  was  exposed  in  the  upper  part 
of  Scarpa's  triangle;  i  c.c.  of  0.5  per  cent,  cocain  solution  was  in- 
jected into  the  artery  in  the  course  of  the  blood-stream,  and  tests 
for  anesthesia  were  immediately  made.  The  experiment  was  in  each 
case  controlled  by  testing  the  sensibility  of  the  other  leg  and  distant 
parts  of  the  body.  The  following  uniform  results  were  obtained: 
Irritation  of  the  anesthetized  leg  caused  no  response;  that  is,  the  ani- 
mal gave  no  evidence  of  pain,  as,  for  instance,  by  drawing  away  the 
leg.  Irritation  of  the  opposite  leg  was  invariably  followed  by  all  the 
evidences  of  pain. 

"Experiment  i.  The  bone  was  exposed  as  roughly  as  possible, 
the  knife  rubbed  up  and  down  on  the  bone,  stripping  the  periosteum. 
No  pain. 

"Experiment  2.  The  femur  was  broken  by  manual  force  and  the 
two  ends  of  the  bone  rubbed  roughly  together. 

"Experiment  3.  The  foot  was  charred  with  a  Bunsen  flame.  No 
evidence  of  pain. 

"Experiment  4.  The  femoral  artery  was  torn,  causing  great 
hemorrhage,  and  necessitating  the  abandonment  of  the  experiment. 
This  accident,  very  likely  to  occur  in  the  thin-walled  artery  of  a 
rabbit,  is  impossible,  as  will  be  shown,  in  the  thicker  walled  artery 
of  a  dog  or  man. 

"Experiments  5  and  6  were  in  all  respects  similar  to  the  preceding 
experiments,  and  need  not  be  detailed. 

"The  disadvantage  of  working  on  rabbits  is  manifest.  The  punc- 
ture of  the  thin-walled  artery  was  invariably  followed  by  hemor- 
rhage, necessitating  the  killing  of  the  animal  after  the  experiment. 
The  perfection  of  the  anesthesia  was  determined,  it  is  true,  by  the 


INTRA- ARTERIAL   ANESTHESIA  213 

rabbit  experiments,  but  not  its  freedom  from  danger.  Therefore 
another  series  of  experiments  was  done  on  dogs  and  the  animals 
allowed  to  live. 

"Experiment  7.  Large  black-and-tan  dog.  Under  ether  anes- 
thesia the  femoral  artery  was  exposed  and  2  c.c.  of  0.5  per  cent,  cocain 
solution  injected  into  the  artery.  The  animal  was  then  lifted  from 
the  dog  board  and  allowed  to  recover  from  the  anesthesia.  After 
fifteen  minutes  the  dog  seemed  perfectly  normal,  running  about  the 
room  in  the  usual  way.  It  was  particularly  noticed  that  there  was 
an  absence  of  any  muscular  paralysis.  The  animal  was  now  tested 
for  anesthesia.  The  anesthetized  leg  was  pinched,  scratched,  and 
slightly  burned.  No  symptoms  of  pain  were  elicited.  Irritation  of 
the  other  leg  and  other  parts  of  the  body  gave  immediate  response. 
After  testing  the  anesthesia  for  half  an  hour  the  wound  was  united 
with  a  continuous  suture.  During  the  maneuver  the  most  perfect 
demonstration  of  the  anesthesia  was  obtained.  The  point  of  injec- 
tion into  the  artery  lay  about  the  middle  of  the  wound.  The  lower 
half  of  the  wound  was  sutured  without  any  evidence  of  pain,  the 
animal  lying  perfectly  quiet  and  seemingly  unconcerned.  As  soon 
as  the  needle  entered  the  skin  above  the  point  of  injection  the  animal 
gave  all  evidences  of  severe  pain — squealing  and  struggling.  This 
demonstrated  that  the  anesthesia  extends  to  the  point  of  injection. 
The  dog  was  watched  for  a  week,  during  which  no  untoward  symp- 
toms were  evidenced.  The  animal  then  escaped,  none  the  worse  for 
his  experience. 

"Experiment  8  was  in  every  particular  similar  to  the  above  ex- 
periment. The  subject  was  a  smaller  animal,  and  only  i  c.c.  of  0.5 
per  cent,  cocain  solution  was  used. 

"Experiment  9  is,  according  to  present  indications,  more  of  scien- 
tific interest  than  of  practical  value.  The  dog  was  large..  Under 
ether  anesthesia  the  common  carotid  artery  was  exposed  and  2  c.c. 
of  0.5  per  cent,  cocain  solution  injected  into  the  artery.  The  wound 
was  closed  with  a  continuous  suture  and  the  animal  allowed  to  re- 
cover from  the  anesthesia.  After  about  fifteen  minutes  recovery 
was  complete  and  the  animal  was  apparently  normal.  What  was 
most  interesting  was  the  complete  absence  of  any  deviation  from 
normal  intelligence.  The  animal  ate  and  drank  from  a  bowl,  also 
gave  evidence  of  knowing  what  was  going  on  about  him.  The  ani- 
mal was  now  tested  for  anesthesia.  The  results  were  most  gratifying. 
There  was  a  complete  anesthesia  of  the  entire  head,  face,  and  upper 
part  of  the  neck.  The  skull  was  exposed  and  a  piece  of  bone  chipped 


214  LOCAL   ANESTHESIA 

out.  Deep  incisions  were  made  into  the  skin  of  the  face,  ears,  and 
neck.  Even  the  very  sensitive  nose  and  lips  were  scarified  without 
causing  pain.  Irritation  of  other  parts  of  the  body  elicited  symptoms 
of  pain.  The  bilateral  anesthesia  of  the  face  and  head  may  be  ex- 
plained by  the  very  free  anastomosis  between  the  two  carotid  sys- 
tems. A  very  interesting  feature  of  this  experiment  is  that  sight 
was  not  interfered  with,  as  shown  by  persistence  of  lid  reflexes. 

"Experiment  10.  Medium-sized  dog.  Under  ether  anesthesia 
the  femoral  artery  was  exposed  and  i  c.c.  of  0.5  per  cent,  novocain 
solution  was  injected.  The  experiment  was  a  failure,  the  dog  show- 
ing no  diminution  of  sensation. 

"The  nature  of  the  anesthesia  is  terminal — that  is,  the  cocain  is 
carried  by  the  capillaries  to  the  individual  nerve-endings.  The  solu- 
tion is  diffused  through  the  capillary  walls  into  the  surrounding  tis- 
sues, and  very  little,  if  any,  is  returned  through  the  veins  to  the 
general  circulation.  This  is  shown  by  the  purely  local  character  of 
the  anesthesia. 

"The  following  technic  is  to  be  used  in  man:  The  main  artery 
supplying  the  part  to  be  anesthetized  is  exposed  under  infiltration 
anesthesia.  An  Esmarch  strap  is  now  bound  around  the  limb  some 
distance  above  the  point  of  proposed  injection  into  the  artery.  The 
Esmarch  should  be  used  as  in  the  Bier  hyperemic  treatment;  that  is, 
snug  enough  to  constrict  the  veins,  but  not  so  tight  as  to  interfere 
with  the  arterial  circulation.  From  4  to  8  c.c.  of  0.5  per  cent,  cocain 
in  normal  salt  solution  should  be  injected  into  the  artery  in  the  direc- 
tion of  the  blood-stream.  The  needle  used  should  be  as  fine  as  pos- 
sible. After  anesthesia  is  complete  the  Esmarch  may  be  tightened 
if  perfect  hemostasis  is  desired.  At  the  end  of  the  operation  the 
Esmarch  is  removed  and  the  wound  closed.  The  maximum  dose 
suggested,  that  is,  8  c.c.  of  0.5  per  cent,  cocain  solution,  con  tains  only 
0.6  cocain,  a  safe  dose.  This  method  of  anesthesia  is  an  ideal  one 
for  certain  areas  of  the  body  when  general  anesthesia  is  contra- 
indicated.  It  is  particularly  applicable  to  the  upper  extremity, 
where  the  brachial,  radial,  or  ulnar  artery  may  be  exposed  with  little 
difficulty." 

In  commenting  upon  the  procedure,  particularly  Experiment  9, 
in  which  2  c.c.  of  0.5. per  cent,  cocain  was  injected  into  the  common 
carotid  artery  (he  does  not  say  which  side)  and  produced  a  "com- 
plete anesthesia  of  the  entire  head,  face,  and  upper  part  of  the  neck," 
while  not  questioning  the  correctness  of  the  observations,  it  is  inter- 
esting to  know  just  how  the  cocain  acted.  Was  it  distributed  to  the 


INTRA-ARTERIAL    ANESTHESIA  21$ 

parts  by  the  external  carotid  on  the  side  injected?  If  so,  it  is  diffi- 
cult to  understand  how  it  reached  the  other  side  in  sufficient  quan- 
tities to  produce  anesthesia,  unless  the  external  carotid  of  that  side 
had  been  previously  ligated;  in  this  case  the  blood  could  easily  cross 
over  through  the  numerous  anastomoses.  Or,  did  it  reach  the  cen- 
ters of  the  fifth  nerve  (the  nerve  principally  concerned  in  the  sensa- 
tion of  these  parts)  in  the  floor  of  the  fourth  ventricle  through  the 
distribution  of  the  internal  carotid  artery?  If  this  were  the  case,  it 
is  more  readily  understood  how  both  sides  were  equally  affected ;  but, 
on  the  other  hand,  the  rest  of  the  brain  was  bathed  in  a  solution  of 
the  drug  equally  as  strong,  and  should  have  shown  more  disturbance 
of  sensation  of  the  entire  body  as  well  as  paralyzing  other  centers. 
Just  where  the  general  centers  for  the  pain  are  we  do  not  know ;  but 
we  know  that  it  is  the  brain  that  feels,  and  that  it  is  capable  of  gen- 
eral anesthesia  by  cocain  injected  into  the  blood-current,  as  shown 
by  Dr.  Harrison's  experiments  upon  himself,  mentioned  elsewhere  in 
this  volume,  and  Ritter's  experiments  upon  dogs.  (See  General 
Anesthesia  with  Cocain.) 

The  fatal  dose  of  cocain  injected  into  the  arteries  is  eight  to  ten 
times  greater  than  the  intravenous  dose  (Oppel),  but  here  he  was 
speaking  of  arteries  in  the  extremities,  where  the  effect  of  the  cocain 
was  largely  reduced  and  weakened  by  making  the  circuit  of  the 
blood-stream,  and  much  of  it  being  fixed  by  contact  with  the  com- 
paratively large  capillary  area.  As  its  toxic  action  is  due  entirely  to 
the  amount  of  the  drug  reaching  the  central  nervous  system  through 
the  circulation,  when  delivered  into  such  arteries  as  the  carotid,  the 
ratio  between  the  intravenous  and  intra-arterial  toxicity  must  here 
be  reversed  and  the  intra-arterial  dose  here  be  many  times  smaller. 
Besides,  when  delivered  intravenously  most  of  that  reaching  the 
heart  is  distributed  to  the  trunk  and  peripheral  parts  with  the  bulk 
of  the  circulation,  and  only  a  small  part  of  it,  certainly  not  over  one- 
fourth,  reaching  the  brain  by  the  vessels  going  in  that  direction. 
With  these  facts  it  is  hard  to  reconcile  the  two  observations,  that  by 
Dr.  Harrison,  who  injected  5  gr.  intravenously  in  himself  in  thirty 
minutes  and  obtained  general  anesthesia  of  the  entire  body,  and  that 
of  Dr.  Ransohoff,  who  injected  into  the  carotid  2  c.c.  of  a  0.5  per  cent, 
solution,  0.15  gr. ;  although  the  dog  was  large,  it  must  have  been  a 
relatively  good-sized  dose  for  that  method  of  administration,  and  pro- 
duced only  an  anesthesia  of  the  head,  face,  and  upper  part  of  the 
neck.  Letting  alone  the  action  of  the  drug  in  this  particular  case  of 
carotid  injection,  the  method  of  arterial  anesthesia  is  certainly  in- 


2l6  LOCAL   ANESTHESIA 

genious  and  of  scientific  interest.  It  is  too  early  yet  to  state  of  what 
practical  value  it  may  become,  as  the  writer  has  had  but  a  limited 
experience  with  the  method,  and  it  has  had  but  a  limited  trial  in  the 
hands  of  others  who  have  introduced  it.  The  fact  that  the  main 
artery  of  the  part  must  first  be  exposed  is  not  in  itself  an  objection, 
for  the  same  dissections  frequently  are  made  to  expose  nerves  for 
regional  anesthesia.  Of  course  the  method  should  be  tried  only  in 
those  having  healthy  arteries;  in  such  vessels  the  puncture  of  a  fine 
hypodermic  needle  is  not  likely  to  be  followed  by  any  after-result. 
It  would,  however,  seem  preferable,  in  operating  upon  the  extremi- 
ties, where  infiltration  and  nerve-blocking  cannot  be  used,  to  use 
venous  anesthesia,  which  is  a  simpler  method,  and  when  properly 
carried  out  produces  very  satisfactory  results  and  is  free  from  any 
possible  after-effects. 

The  following  case,  operated  upon  by  the  author,  presents  some 
features  of  interest: 

M.,  an  aged  man,  presented  an  advanced  carcinoma  of  the  parotid  gland,  with  his 
general  condition  contra-indicating  the  use  of  general  anesthesia.  It  was  decided  to 
ligate  the  external-  carotid  at  its  origin,  as  a  preliminary  step,  after  first  utilizing  it  for 
arterial  anesthesia.  The  problem  then  presented  itself  as  to  how  soon  after  the  injection 
should  the  ligature  be  applied;  if  done  too  soon  no  good  would  be  accomplished,  as  the 
injected  solution,  not  having  reached  the  capillaries,  could  not  readily  diffuse  into  the 
tissues,  and  if  delayed  too  long  it  would  be  swept  into  the  return  circulation. 

Adrenalin  was  accordingly  utilized  for  determining  the  proper  time  for  the  applica- 
tion of  the  ligature.  After  free  exposure  of  the  carotid,  with  the  ligature  in  place  but  not 
tied,  5  cc.  of  a  i  per  cent,  novocain  solution,  containing  15  drops  of  adrenalin  (i:  1000), 
was  now  slowly  injected  with  a  fine  needle;  in  ten  seconds,  and  before  the  entire  quantity 
had  been  injected,  the  effect  came  like  a  flash  in  the  peripheral  parts;  the  face,  cheek,  and 
parotid  region,  previously  florid  with  dilated  capillaries,  was  suddenly  blanched  almost 
a  perfect  white;  the  effect  was  so  sudden  and  complete  that  it  was  startling  and  extended 
over  the  entire  side  of  the  face  and  head;  the  remaining  solution  was  now  quickly  injected 
and  the  ligature  tied. 

Tests  for  sensibility  showed  a  decided  diminution  over  the  entire  blanched  area,  but 
not  sufficient  to  permit  operation.  This  was  probably  due  to  the  small  amount  of  novo- 
cain used,  and  its  too  slow  injection  to  permit  of  the  maximum  amount  reaching  the 
peripheral  parts  at  one  time  in  such  a  vascular  region.  We  now  injected  the  trigeminus 
at  the  base  of  the  skull  and  obtained  perfect  anesthesia,  proceeding  with  the  operation  in 
a  completely  ischemic  field. 

This  procedure  of  the  utilization  of  adrenalin  suggests  itself  as  a 
simple  and  reliable  means  of  determining  when  the  injected  anesthetic 
has  reached  the  capillaries  and  may  prove  a  useful  adjunct.  It  also 
occurred  to  the  author  that  it  might  find  an  occasional  field  of  useful- 
ness in  ligating  a  large  vessel  in  the  presence  of  anomalous  arterial 
formation  when  other  tests,  as  peripheral  pulse,  etc.,  give  uncertain 
results. 


INTRA-ARTERIAL   ANESTHESIA 


INTRAVENOUS  ANESTHESIA 

This  unique  and  simple  method  of  anesthesia  was  introduced  by 
Prof.  August  Bier,  of  Berlin,  to  whom  medical  science  already  owes 
much.  In  addition  to  this,  his  latest  dis- 
covery in  this  field,  he  has  done  much  to- 
ward spinal  analgesia  in  placing  it  upon  the 
plane  which  it  now  occupies.  This  method 
was  first  presented  by  Bier  before  the  Thirty- 
seventh  Congress  of  German  Surgeons,  April, 
1908.  It  is  applicable  only  to  the  extremi- 
ties. The  limb  to  be  operated  upon  is  first 
rendered  completely  ischemic  by  an  Esmarch 
or  soft-rubber  bandage  applied  from  the  distal 
end  to  a  point  above  the  proposed  site  of  in- 
jection. This  must  be  done  thoroughly,  the 
presence  of  blood  in  the  veins  interfering  with 
the  production  of  a  perfect  anesthesia.  A 
soft-rubber  bandage  (the  kind  used  for  stasis 
hyperemia)  is  now  applied  at  the  upper  part 
of  the  ischemic  area ;  it  must  be  tight  enough 
to  prevent  the  circulation  entering  the  part, 
and  should  be  applied  over  a  broad  area,  so 
that  the  pressure  does  not  become  painful. 
A  second  similar  bandage  is  placed  below  the 
proposed  site  of  injection,  from  4  to  6  inches 
below  the  first.  Under  infiltration  anesthesia 
the  vein  is  now  exposed.  The  principal  vein 
of  the  part  should  be  selected  and  not  one  of 
its  radicles.  In  the  case  of  the  leg,  the  saphe- 
nous;  in  the  case  of  the  arm,  the  median 
cephalic  or  median  basilic,  or  one  of  their 
large  trunks,  in  case  the  injection  is  made 

below  the  elbow.     The  vein  should  be  ex-   .     , lg'  j7'    ",.'.  ,e 

imal;  c-d,  the  distal  or  per- 

posed  as  near  the  upper  bandage  as  possi-    ipheral  bandage;  vb,  vena 
ble,  ligatures  passed  around  it,  and  the  upper    basilica;  vc,  vena  cephalka; 

end  tied.     An  infusion  cannula  is  now  passed    vm'  vena  media;   +>  ?e 

.         place    where    the   injection 
into   its  lumen,  either   through  an  opening    may  be  made  in  the  ceph. 

Or    by     having     the     vein     sectioned     across,     alic  and  at  a  corresponding 

This    is   firmly    secured   in    the    lumen    of    Point.  in  the  basilic  veins- 
, ,  .  ,     , ,  . ,     . .  ,  .         Shading  shows  area  of  sen- 

the   vein   and    the    anesthetic    solution    in-    sibility  below  the  proximal 

jected  through  the  cannula.     If  the  operation    bandage  (Bier). 


2l8  LOCAL   ANESTHESIA 

is  upon  the  upper  extremity,  50  c.c.  of  0.5  percent,  novocainin  normal 
salt  solution  is  used;  if  upon  the  lower  extremity,  80  c.c.  of  the  same 
solution  is  used.  Any  large  syringe  can  be  used  for  making  the  in- 
jection, although  to  facilitate  the  work  a  special  syringe  has  been 
devised  (Fig.  28).  A  stout  piece  of  tubing  can  be  used  for  making  the 
connection  between  the  nozzle  of  the  syringe  and  the  cannula  within 
the  vein ;  it  must  be  firmly  attached  to  both  and  the  syringe  be  in 
good  working  order,  as  it  requires  some  little  pressure  to  drive  the 
solution  into  the  veins.  The  Matas  infiltration  apparatus  is  admirably 
suited  for  this  injection.  The  injection  should  not  be  made  too  rapidly, 
but  done  slowly,  allowing  time  for  the  solution  to  flow  into  the  veins, 
which  are  seen  slowly  distending  as  they  are  filled  with  the  solution. 
The  solution  diffuses  through  the  vein  walls  into  the  surrounding 
tissues,  the  distended  veins  becoming  less  and  less  distinct  until  they 


Fig.  28. — Large  syringe  for  Bier  intravenous  anesthesia.     (From  Braun.) 

are  no  longer  discernible.  The  valves  in  the  veins  offer  no  obstruc- 
tion to  the  injection,  as  they  are  forced  by  the  fluid  and  the  distention 
of  the  veins. 

Anesthesia  is  said  to  be  produced  almost  immediately  in  the  area 
between  the  bandages  (direct  anesthesia) .  In  the  parts  distal  to  the 
lower  bandage  anesthesia  is  complete  in  from  fifteen  to  twenty  min- 
utes (indirect  anesthesia) .  Anesthesia  does  not  reach  quite  to  the 
upper  bandage,  and  frequently  leaves  a  strip  on  the  side  opposite  to 
the  vein  which  reaches  down  to  the  second  bandage  only  partially,  or 
not  at  all,  anesthetic. 

The  circumferential  spread  of  the  anesthetic  solution  can  be 
favored  and  increased  by  massage  and  kneading  of  the  parts  after  the 
injection  has  been  made  and  while  waiting  for  the  anesthesia  to 
develop. 


INTRA- ARTERIAL    ANESTHESIA  219 

The  muscular  relaxation  is  said  to  be  more  prompt  and  pro- 
nounced than  under  ether  anesthesia. 

The  duration  of  the  anesthesia  is  absolutely  under  control  and  per- 
sists as  long  as  the  upper  bandage  remains  in  place,  and  rapidly 
disappears  after  the  removal  of  the  latter,  sensation  returning  in  a 
very  few  minutes.  For  this  reason  it  is  necessary  that  the  entire 
operation  be  completed  and,  if  possible,  the  dressings  applied  before 
the  upper  bandage  is  removed.  The  duration  of  the  operation  is  said 
to  bear  no  relation  to  the  rapidity  of  the  return  of  sensation. 

Care  should  be  exercised  in  securing  all  bleeding-points,  which  are 
easily  overlooked  when  operating  by  this  method.  Salt  solution  in- 
jected through  the  cannula,  when  operating  in  the  area  of  direct 
anesthesia,  may  be  used  to  show  the  points  of  venous  hemorrhage. 
After  the  completion  of  the  operation  the  veins  may  be  washed  out 
with  salt  solution  to  remove  any  excess  of  the  anesthetic  solution 
which  may  still  remain  in  them.  This  process  does  not  lessen  the 
anesthesia  or  seem  to  hasten  the  return  of  sensation,  which  confirms 
the  observation  that  the  anesthetic  agents  have  formed  compounds 
with  the  tissue-cells  which  is  only  broken  up  by  nutrition  with  arte- 
rial blood. 

In  the  numerous  cases  reported  operated  on  by  this  method  no 
cases  of  intoxication  from  the  anesthetic  used  have  been  recorded. 

In  the  case  of  amputation,  or  extensive  operation  in  the  area  of 
direct  anesthesia,  the  washing-out  process  of  the  veins  may  be  omit- 
ted, as  the  incisions  furnish  ample  opportunities  for  the  escape  of  any 
excess  of  solution. 

In  preparing  the  limb  for  injection  it  is  said  to  cause  less  discom- 
fort to  sensitive  patients  if  the  main  artery  of  the  part  is  first  com- 
pressed and  the  limb  elevated  and  rendered  ischemic  in  this  position. 
Should  the  pressure  from  the  upper  bandage  become  troublesome  to 
the  patient  during  operation,  an  additional  bandage  can  then  be 
applied  within  the  anesthetic  area  and  the  upper  one  removed. 

Precautions  suggested  to  guard  against  toxemia  in  addition  to  the 
washing-out  process  above  mentioned  are  to  release  the  bandages 
gradually  after  the  completion  of  the  operation  or  to  tighten  the 
upper  one  after  it  has  been  released  for  a  few  moments. 

Here,  as  in  all  major  operations  under  any  method  of  local  or 
regional  anesthesia,  it  is  desirable  to  give  a  preliminary  hypodermic 
of  morphin,  y§  gr.,  with  scopolamin,  ^50  gr.,  about  one  hour  before 
the  operation.  It  greatly  lessens  the  fears  and  anxiety  of  the  patient 
and  overcomes  any  undue  sensitiveness. 


22O  LOCAL   ANESTHESIA 

The  operative  possibilities  under  this  method  are  not  limited  to' 
any  particular  class  of  operations,  but  include  the  entire  range  of 
surgical  interventions  upon  these  parts. 

The  only  centra-indications  mentioned  for  this  method  are  dia- 
betes, advanced  arteriosclerosis,  and  senile  gangrene. 

In  a  recent  article  Prof.  Bier  has  suggested  exposing  the  vein 
under  local  anesthesia  before  rendering  the  parts  ischemic  and  identi- 
fying it  by  passing  a  ligature  around  it,  as  it  is  not  always  easy  to 
recognize  the  one  wanted  in  ischemic  tissues,  particularly  if  sur- 
rounded by  much  fat;  the  field  can  then  be  covered  by  a  sterile 
towel  and  the  process  proceeded  with. 


CHAPTER  XIII 

GENERAL  ANESTHESIA  THROUGH  THE  INTRAVENOUS 
INJECTION  OF  LOCAL  ANESTHETICS 

RITTER,  experimenting  in  Payr's  clinic,  produced  complete  general 
analgesia  by  injecting  into  superficial  veins  of  dogs  10  c.c.  of  a  i  per 
cent,  solution  of  cocain,  or  5  c.c.  of  a  3  or  5  per  cent,  solution  in  a  o.i 
per  cent,  salt  solution.  The  animals  lay  perfectly  quiet,  but  alert. 
Respiration  and  circulation  were  not  disturbed,  but  they  were  com- 
pletely insensible  to  every  kind  of  irritation  that  could  be  used,  even 
to  the  actual  cautery  applied  to  the  penis,  vagina,  anus,  tail,  face,  ear, 
and  lining  of  the  mouth.  There  was  no  sign  of  pain,  and  the  dogs 
wagged  their  tails  during  these  performances.  Only  when  forceps 
were  applied  to  the  tongue  did  they  seem  to  object,  but  here  not 
apparently  from  pain. 

The  duration  of  the  anesthesia  was  from  fifteen  to  twenty  min- 
utes or  longer,  and  was  not  followed  by  serious  after-disturbances. 
Only  a  few  showed  any  unpleasant  by-effects,  and  these  were  small 
animals  upon  which  the  larger  doses  had  been  used.  One  dog,  how- 
ever, always  reacted  in  the  same  way,  even  to  small  doses.  The 
disturbances  were  always  of  the  same  kind,  the  animal  becoming  very 
restless,  tossing  his  head  about,  and,  if  placed  on  the  floor,  ran  around 
in  circles.  This  would  continue  for  about  fifteen  minutes,  after 
which  time  the  animal  quieted  down  and  remained  apparently  nor- 
mal. Actual  convulsions  were  never  observed  with  any  dosage. 
None  of  the  larger  dogs  showed  any  by-effects. 

Still  more  interesting  are  the  observations  made  by  Dr.  B.  W. 
Harrison  upon  himself,  and  reported  in  the  Boston  Med.  and  Surg. 
Jour.,  February  2,  1911.  The  doctor  showed  great  courage  in  using 
upon  himself,  by  the  method  he  employed,  what  would  have  been 
considered  a  thoroughly  toxic  dose  of  the  drug;  but  he  observed  the 
precaution  of  proceeding  very  slowly  and  stopping  with  the  first 
unpleasant  symptoms.  He  states  that,  except  for  minor  operations, 
there  had  been  no  other  use  of  cocain  or  allied  drugs  upon  himself. 
The  experiment  was  performed  as  follows: 

Into  one  of  the  superficial  veins  on  the  back  of  the  hand  there 
was  slowly  injected  5  gr.  of  cocain  in  a  2  per  cent,  solution.  The 


222  LOCAL   ANESTHESIA 

injection  was  made  very  slowly,  and  was  completed  in  thirty  minutes. 
It  was  deemed  advisable  to  stop  here,  as  dizziness  and  palpitation 
occurred.  Tests  of  the  patient's  condition  as  to  general  anesthesia 
were  now  made,  and  were  found  to  conform  in  an  incomplete  way 
with  those  observed  in  animals  similarly  experimented  with.  There 
was  fairly  marked  analgesia  everywhere.  An  incision  %  inch  long, 
and  carried  well  down  into  the  fat,  was  made  on  the  anterior  surface 
of  the  leg.  The  incision  could  be  felt,  but  caused  a  mere  trifle  of  pain. 
When  several  small  nerves  in  the  fat  were  cut  each  caused  a  small 
twinge  of  pain,  but,  apparently,  operative  procedure  might  readily 
have  been  undertaken  with  only  moderate  discomfort.  Two  hours 
later  a  similar  incision  was  made  on  the  opposite  leg;  by  now  the 
sensation  of  pain  had  nearly  recovered  its  normal  intensity.  During 
the  experiment  cerebration  was  normal,  except  for  a  restless  inability 
to  keep  the  mind  long  on  one  subject.  Motor  power  was  unimpaired. 

This  experiment  and  those  on  dogs  by  Ritter  are  highly  interesting, 
and,  at  least,  of  scientific  value.  The  enormous  dose  necessary  upon 
Dr.  Harrison,  and  then  producing  only  an  imperfect  analgesia,  makes 
it  an  impossibility  in  human  surgery.  The  dose  used  by  Dr.  Harrison 
was  several  times  that  necessary  to  show  toxic  symptoms,  and  may 
have  proved  fatal  had  he  injected  it  all  at  once,  but  he  made  the  in- 
jection slowly  over  a  period  of  thirty  minutes. 

It  is  interesting  to  compare  the  results  obtained  by  these  injec- 
tions with  that  by  Prof.  Ransohoff,  when  he  injected  0.15  gr.  of  cocain 
in  the  common  carotid  of  a  dog,  and  obtained  only  analgesia  of  the 
head,  face,  and  upper  part  of'  the  neck.  (See  Arterial  Anesthesia, 
Experiment  9,  and  the  discussion  which  follows.) 

A  comparison  of  the  toxicity  of  cocain,  when  injected  in  the  various 
ways,  is  given  by  Oppel  as  follows: 

"Subcutaneous  injections  are  two  to  three  times  less  dangerous 
than  the  arterial  and  fifteen  to  twenty  times  less  dangerous  than  the 
intravenous  injection,  and  arterial  injections  are  eight  to  ten  times 
less  dangerous  than  the  intravenous."  (Here  he  was  no  doubt  ex- 
perimenting with  arteries  of  the  extremities,  but  he  does  not  state.) 

Meyer  in  experimenting  with  intravenous  injections  of  cocain  for 
the  production  of  general  anesthesia  corroborated  the  findings  of 
previous  investigators  but  discovered  that  the  large  nerve-trunks 
remained  as  sensitive  to  pain  as  before,  even  with  very  large  doses  of 
cocain,  and  that  the  anesthesia  seemed  limited  to  the  peripheral  nerve- 
terminals  to  which  it  is  carried  by  the  blood.  To  confirm  this  as- 
sumption one  leg  was  ligated  before  the  injection  was  given,  so  that 


GENERAL   ANESTHESIA  223 

the  circulation  was  cut  off;  following  the  injection  the  entire  body 
became  anesthetic  except  this  leg. 

These  methods  at  present  are  of  scientific  rather  than  practical 
interest  but  may  become  of  some  importance,  like  the  intravenous 
use  of  ether,  with  the  discovery  of  safer  agents  than  those  now  in  use. 

It  is  also  known  that  magnesium  sulphate  when  injected  intraven- 
ously produces  a  general  anesthesia,  but  this  agent  is  too  toxic  and 
depressing  for  clinical  use.  (See  this  subject.) 


CHAPTER   XIV 
THE  UPPER  AND  LOWER  EXTREMITIES 

"  As  a  general  proposition,  it  may  be  safely  asserted  that  all  opera- 
tions can  be  made  painless  by  local  or  regional  anesthesia  in  all  parts 
of  the  body  in  which  the  circulation  can  be  absolutely  controlled  by 
circular  constriction.  Hence,  the  entire  surgery  of  the  upper  and 
lower  limbs  (with  exceptions  to  be  considered  later)  can  be  made 
tributary  to  these  methods.  It  is  in  the  surgery  of  the  extremities 
that  the  combined  local  (infiltrations)  and  regional  (neural)  anesthe- 
sia has  attained  its  degree  of  efficiency  and  accomplished  its  most 
convincing,  if  not  most  brilliant,  results.  On  the  other  hand,  the 
efficiency  and  applicability  of  these  methods  is  decidedly  restricted, 
impaired,  and  at  times  wholly  inefficient  at  the  root  of  the  limbs. 
This  is  more  especially  the  case  in  the  hip  and  gluteal  regions,  where, 
on  account  of  the  overlapping  of  the  cutaneous  nerve  distribution  and 
because  of  the  great  depth  of  the  most  important  nerves — as,  e.g., 
the  sciatic,  where  it  issues  from  the  pelvis — it  is  impossible  to  expose 
the  great  nerve-trunks  without  inflicting  an  additional  traumatism, 
which  is  scarcely  compatible  with  the  conservative  aims  of  the  local 
anesthetic  methods. 

"It  is  only  fair  to  state  that  these  objections  do  not  apply  to  all 
cases,  and  that  even  in  these  most  difficult  regions  many  perfect 
successes  can  be  obtained  by  purely  local  and  intraneural  methods 
when  they  are  applied  to  suitable  subjects.  This  is  particularly  true 
of  emaciated,  wasted  patients,  in  whom  disarticulation  at  the  hip 
can  be  performed  by  simple  edematization  and  intraneural  infiltration 
as  effectively  as  in  the  minor  amputations  and  disarticulations  of  the 
fingers  and  toes"  (Matas). 

In  the  upper  extremities  the  difficulties  to  be  encountered  are 
much  more  successfully  met  by  the  comparatively  easy  access  to  the 
brachial  plexus,  which  can  be  exposed  and  infiltrated  above  the 
clavicle. 

But  whatever  doubts  may  exist  as  to  the  invariable  success  of 
cocain  and  its  allies  in  controlling  the  sensibility  of  the  root  of  the 
limbs,  there  can  be  no  doubt  in  asserting  that  all  operations,  in- 
cluding amputations,  disarticulations,  and  excisions  below  the  in- 
sertion of  the  deltoid  in  the  arm,  and  below  the  middle  third  of  the 
thigh  in  the  lower  limbs,  can  be  made  painless  by  purely  local  or 

224 


THE    UPPER   AND    LOWER   EXTREMITIES  225 

neural  (peripheral)  methods  of  anesthesia.  In  anesthetizing  the 
extremities,  the  methods  will  vary  with  the  individual  regions,  and 
the  technic  will  demand  more  skill  and  anatomic  knowledge  as  the 
surgeon  proceeds  from  periphery  to  center.  In  all  major  procedures, 
in  which  a  large  part  of  the  thickness  and  circumference  of  the  limb 
is  to  be  exposed  to  the  knife  and  to  painful  manipulations,  the  neuro- 
regional  method  is  to  be  preferred,  as  in  excision  of  bones  and  joints 
and  in  amputations.  In  more  superficial  or  well-circumscribed 
lesions  the  simple  infiltration  method  of  Schleich  will  be  most  appli- 
cable. In  thin  and  marasmic  subjects  this  method  will  also  find  fre- 
quent and  ready  application  because  of  its  greater  simplicity,  even 
when  amputations  are  required,  provided  they  are  strictly  typical 
and  do  not  involve  extensive  excursions  away  from  the  infiltrated 
area.  But  whether  the  method  adopted  be  the  edematization  of 
Schleich  or  the  neuroregional  method,  the  circular  elastic  constrictor 
applied  on  the  Corning  principle  should  be  applied  after  the  analgesic 
drug  has  been  injected  and  the  exsanguination  of  the  limb  by  eleva- 
tion and  gravity  has  been  obtained. 

The  introduction  of  vein  anesthesia  by  Bier  has  greatly  simplified 
all  procedures  upon  the  extremities  where  this  method  can  be  em- 
ployed; however,  there  still  remain  many  conditions  in  which  it 
cannot  be  successfully  used — the  necessary  appliances  may  not  be  at 
hand,  or  the  operator  may  prefer  to  use  other  methods. 

The  ability  to  control  the  blood-supply  in  the  extremities  greatly 
facilitates  all  surgical  procedures  in  these  parts,  and  in  the  use  of 
local  anesthetics  intensifies  and  prolongs  their  action. 

The  course  of  the  long  cutaneous  trunks  is  fairly  constant  in  both 
upper  and  lower  extremities,  and  should  be  carefully  studied,  as  well 
as  their  points  of  emergence  through  the  deep  fascia ;  the  smaller  cuta- 
neous branches  are,  however,  subject  to  variations  within  certain 
limits,  and  cannot  always  be  definitely  located.  But  the  main 
trunks  of  these  parts  are  quite  constant  throughout  their  entire  course 
and  can  be  easily  reached,  either  through  deep  paraneural  injections 
along  their  course  or  by  free  exposure  and  direct  (intraneural)  in- 
jections. 

BONES  AND  JOINTS 

In  all  operations  upon  the  bones  it  must  be  remembered  that  bone 
and  cartilage  have  no  sensation,  but  that  the  periosteum,  perichon- 
drium,  and  synovial  membranes  are  nearly  as  sensitive  as  the  skin; 
bone-marrow  is  also  slightly  sensitive. 

15 


226  LOCAL   ANESTHESIA 

In  operating  here  by  infiltration  the  periosteum  should  be  in- 
cluded; after  this  has  been  infiltrated  or  denuded  from  the  bone  no 
further  sensation  is  felt. 

In  operating  upon  bones  for  inflammatory  conditions,  such  as 
periostitis  or  osteomyelitis,  it  is  preferable  always  to  use  the  regional 
methods  of  anesthesia.  In  cases  where  this  is  not  feasible,  or  in  the 
absence  of  inflammations,  where  it  is  preferred  to  operate  by  infiltra- 
tion, as  in  the  removal  of  an  osteophyte  or  for  a  simple  osteotomy,  it 
is  desirable,  where  the  bone  is  superficial  and  easily  accessible,  to 
infiltrate  the  periosteum  before  making  the  incision.  The  infiltration 
is  done  with  a  long  needle  passed  down  from  the  skin  from  two  or  more 
points  and  directed  in  different  directions,  so  as  to  embrace  the  en- 
tire operative  field  on  the  bone  (see  Fig.  15).  In  the  ordinary  case  it 
is  only  necessary  that  the  injections  be  made  proximately  and  on 
each  side,  in  a  somewhat  crescentic  manner,  the  two  horns  embracing 
the  growth.  In  this  way  all  nerve-fibers  leaving  the  field  are  effect- 
ively blocked.  When  an  operative  field  is  sequestered  in  this  way  by 
circumferential  or  crescentic  injections  it  is  n6cessary  to  wait  about 
ten  or  fifteen  minutes  for  full  anesthesia  to  become  established.  In 
case  the  bone  is  deeply  situated  or  overlaid  by  heavy  muscles,  as  in 
the  case  of  the  femur,  it  would  be  preferable  to  anesthetize  the  perios- 
teum later,  after  the  bone  has  been  exposed  by  the  division  of  the  over- 
lying soft  parts.  Where  the  periosteum  has  been  well  anesthetized 
the  use  of  chisels  or  other  bone-cutting  instruments  is  unaccompanied 
by  any  pain.  Such  instruments  should  always  be  sharp  and  the  bone 
cut  obliquely  rather  than  at  right  angles,  to  avoid  the  shock  of  the 
blow,  which  is  always  trying  on  the  patient  even  if  it  causes  no  pain. 
In  operating  by  regional  methods,  the  injections  should  be  made  at 
sufficiently  high  levels  to  include  the  nerve  supply  to  the  periosteum 
when  possible,  otherwise  the  periosteum  will  have  to  be  infiltrated. 
The  humerus  receives  its  nerve-supply  from  the  musculopsiral  and 
musculocutaneous  nerves;  the  radius  and  ulna,  from  the  median 
nerve;  the  elbow-joint  and  wrist  receive  nerves  from  the  three  large 
trunks  in  the  arm;  the  femur,  from  the  sciatic  and  obturator  nerves; 
the  tibia,  from  the  anterior  and  posterior  tibial  nerves;  the  fibula, 
from  the  peroneal;  the  knee-joint,  from  the  internal  and  external 
popliteal,  obturator,  and  crural  nerves. 

The  contents  of  the  joints  contained  within  the  synovial  sacs  can 
be  anesthetized  by  passing  a  needle  into  the  sac  and  filling  it  to  a 
point  of  moderate  distention  with  solution  No.  2  (0.5  per  cent,  novo- 
cain) ,  or  a  slightly  lesser  quantity  of  a  stronger  solution,  and  allowing 


THE   UPPER   AND    LOWER   EXTREMITIES  227 

it  to  remain  for  about  five  minutes,  when  it  can  be  withdrawn  or  will 
escape  from  the  incision.  This  anesthesia  is  only  superficial  and  does 
not  extend  deeper  than  the  synovial  sac,  and  is  suitable  only  for 
drainage  or  simple  incision.  If  more  is  to  be  done,  and  in  cases  where 
much  inflammation  exists,  it  is  better  to  use  some  regional  method  by 
blocking  the  curves  higher  up. 

Fractures. — Local  anesthesia  has  been  used  occasionally  in  reduc- 
ing fractures  of  the  long  bones.  While  in  certain  cases  it  may  be 
useful  where  general  anesthesia  is  contra-indicated,  it  is  certainly  not 
the  method  of  choice,  for  with  it  we  do  not  get  the  complete  muscular 
relaxation  so  necessary  for  the  perfect  reduction  of  the  fractured 
fragments.  Lerda,  in  the  "  Centralblatt  fur  Chirurgie,"  1907,  states 
that  during  the  last  two  years  extensive  use  has  been  made  of  local 
anesthesia  for  fractures  in  Isnardi's  service  at  Turin,  where  he  is 
assistant;  he  applied  this  technic  in  30  cases  before  reduction  of  the 
fracture  and  has  never  observed  the  slightest  inconvenience.  He 
uses  a  long,  strong  needle,  and  injects  the  anesthetic  mixture  at  vari- 
ous points  between  the  fractured  ends  and  tangential  to  them,  so  that 
the  entire  focus  of  the  fracture,  the  bone-marrow,  periosteum  and 
surrounding  tissue  become  impregnated  with  the  anesthetic.  He 
adds  a  drop  of  i  to  1000  solution  of  adrenalin  to  each  cubic  centimeter 
of  a  0.5  per  cent,  solution  of  cocain.  Sometimes  as  much  as  0.08 
gram  of  cocain  (about  i  gr.)  was  injected  without  appreciable  by- 
effects.  The  contraction  of  the  vessels  aids  in  preventing  hematoma 
at  the  point.  The  anesthesia  is  generally  complete  in  about  eight 
minutes.  Not  only  is  the  pain  abolished,  but  the  fracture  can  be 
reduced  much  more  perfectly,  attaining  results  otherwise  impossible 
without  general  anesthesia. 

While  the  method  recommended  by  Lerda  has  the  advantage  of 
simplicity,  it  may  be  preferred  in  many  cases  to  use  regional  anesthe- 
sia, which  produces  a  certain  amount  of  muscular  relaxation,  though 
always  less  than  that  obtained  from  general  anesthesia;  for  this 
reason  general  anesthesia  is  always  to  be  preferred  except  in  those 
cases  which  positively  centra-indicate  its  use;  where  some  form  of 
anesthesia  is  needed  in  complicated  cases,  the  local  or  regional 
methods  may  prove  of  valuable  assistance. 

THE  BRACHIAL  PLEXUS 

The  nerves  of  the  upper  extremity  are  all  derived  from  the  brach- 
ial  plexus  except  the  intercostohumeral ;  the  lateral  cutaneous  branch 


228  LOCAL   ANESTHESIA 

of  the  second  intercostal,  which  crosses  the  axilla,  pierces  the  deep 
fascia  at  the  inner  side  of  the  arm,  and  is  distributed  to  the  skin  of  the 
upper  parts  of  the  arm  on  its  inner  and  posterior  surface;  sometimes 
the  third  intercostal  gives  off  a  similar  branch.  The  brachial  plexus 
is  quite  easily  exposed  and  blocked;  for  this  purpose  it  should  be 
exposed  above  the  clavicle  by  an  incision  running  downward  and  out- 
ward from  the  outer  border  of  the  sternomastoid  over  the  course  of 
the  plexus  (see  Fig.  67),  which  is  easily  recognized  lying  on  the  surface 
of  the  scalenus  medius,  where  each  of  its  branches  may  be  separately 
injected,  each  with  a  few  drops  of  0.5  per  cent,  novocain  solution  with 
a  few  drops  of  adrenalin  to  the  ounce. 

This  is  best  done  in  the  following  manner:  with  a  flat  sand-bag 
under  the  base  of  the  neck  and  the  head  extended  and  rotated  to 
the  opposite  side,  a  line  is  drawn  from  the  middle  of  the  sterno- 
mastoid down  to  the  middle  of  the  clavicle.  A  wheal  is  made  about 
the  center  of  this  line;  with  a  long  fine  needle  and  large  syringe  the 
skin  and  subcutaneous  tissue  along  this  line  are  anesthetized  by  pass- 
ing the  needle  through  the  wheal,  directing  it  up  and  then  down 
just  under  the  skin  along  the  line,  injecting  as  it  is  advanced.  By 
changing  the  angle  it  is  directed  down  beneath  the  deep  fascia 
toward  the  plexus  and  about  one-half  ounce  of  solution  distributed 
here  at  two  or  more  points. 

In  making  these  deep  injections  care  should  be  taken  to  use  only 
a  fine  needle,  preferably  one  with  a  short  beveled  point  such  as  is 
commonly  used  for  spinal  puncture,  also,  always,  to  inject  the  solution 
while  the  needle  is  being  advanced.  At  any  point  should  there  be 
any  question  of  having  entered  a  vessel,  slight  aspiration  upon  the 
syringe  will  show  blood  should  a  vessel  be  entered,  when  the  needle 
can  be  slightly  withdrawn  and  redirected.  Beyond  a  little  staining 
of  the  tissues  no  harm  will  result  from  a  fine  needle  stick,  but  injec- 
tions within  vessels,  particularly  veins,  are  to  be  avoided.  There  is 
practically  no  danger  of  injuring  the  subclavian  vessels,  which  are 
some  little  distance  away,  but  there  are  many  other  small  vessels  in 
the  neighborhood,  and  the  transversalis  coli  with  its  vein,  both  vessels 
of  some  size,  cross  the  field  over  the  plexus.  The  subclavian  artery 
lies  beneath  the  plexus,  the  vein  is  in  front  and  below,  not  rising  as 
high  as  the  artery  and  separated  from  it  by  the  scalenus  anticus. 

Having  finished  the  injections,  and  having  in  mind  the  above 
anatomy,  an  incision  is  made  down  through  the  deep  fascia;  it  may 
be  necessary  to  double  ligate  and  divide  the  transversalis  coli  vessels 
to  obtain  a  free  field.  With  a  little  blunt  dissection  and  palpation 


THE   UPPER   AND    LOWER   EXTREMITIES  229 

the  plexus  is  located  lying  just  above  the  subclavian  artery,  by  lo- 
cating the  pulse  in  this  vessel  with  the  tip  of  the  finger  the  exact 
position  of  the  plexus  is  more  readily  located.  By  keeping  the  shoul- 
der well  depressed  the  plexus  is  easily  brought  into  view. 

The  results  of  an  intraneural  injection  of  the  brachial  plexus  are 
shown  in  from  five  to  ten  minutes  in  a  complete  analgesia  of  the 
shoulder  and  entire  arm,  and  can  be  made  use  of  in  extensive  opera- 
tions upon  these  parts,  and  is  particularly  suited  to  high  amputations 
and  disarticulations  at  the  shoulder.  Where  the  operative  field 
enters  the  region  of  distribution  of  the  intercostohumeral  nerve,  this 
may  be  blocked  by  a  few  drams  of  solution  injected  subcutaneously 
along  the  floor  of  the  axilla  on  its  outer  and  posterior  border.  All 
operations  above  the  elbow,  when  too  extensive  to  be  readily  per- 
formed by  infiltration,  should  be  done  by  blocking  the  brachial 
plexus,  thus  controlling  all  nerves,  superficial  and  deep,  of  this  part  as 
well  as  the  forearm  and  hand.  The  localization  and  injection  of  the 
cutaneous  trunks  of  this  region  is  unsatisfactory,  as  they  are  derived 
from  a  variety  of  sources  and  overlap  each  other;  superficial  or  minor 
operations  should,  therefore,  be  done  through  infiltration,  reserving 
blocking  of  the  brachial  plexus  for  the  more  extensive  or  major  pro- 
cedures. Operations  at  or  near  the  elbow,  involving  extensive  dis- 
sections, resections,  or  amputations,  had  best  be  performed  by  the 
above  method,  which,  of  course,  may  also  be  used  for  any  operation 
on  the  distal  parts  of  the  forearm  or  hand,  but  here  it  would  be  pre- 
ferable to  block  the  nerves  at  the  elbow. 

"We  believed  in  January,  1898,  that  in  cocainizing  the  three  great 
nerves  of  the  arm  at  the  elbow  by  direct  intraneural  infiltration  a 
considerable  territory  had  been  conquered  from  the  domain  of  general 
anesthesia.  We  were  not  then  aware  that  a  few  months  before  our 
first  operation  at  the  Charity  Hospital  the  same  principle  had  been 
successfully  applied  to  the  lower  extremity  by  the  direct  infiltration 
of  the  sciatic  and  anterior  crural  nerves  in  the  performance  of  an 
amputation  of  the  leg.  The  credit  of  applying  this  direct  intraneu- 
ral method  in  major  amputations  is  due,  I  am  pleased  to  say,  to  Dr. 
Geo.  W.  Crile,  of  Cleveland,  Ohio,  whose  remarkable  and  most  ex- 
haustive experimental  study  of  shock  has  made  his  name  familiar  to 
all  readers  of  surgical  literature.  It  was  precisely  with  the  view  of 
diminishing  shock  that  Dr.  Crile  was  led  to  apply  this  method,  which 
he  very  appropriately  designates  the  'blocking  method/  because  the 
infiltration  of  a  nerve-trunk  with  cocain  'blocks'  or  completely  inter- 
rupts the  conduction  of  all  afferent,  irritant  impressions  made  upon 


230  LOCAL   ANESTHESIA 

the  nerve  below  the  blockage.  Crile's  first  operation  was  performed 
May  1 8,  1897,  and  was  suggested  by  the  well-known  experiments  of 
the  physiologists,  U.  Mosso  (1886)  and  Francois  Franck  (1894)" 
(Matas). 

In  a  personal  communication  addressed  to  Dr.  Matas,  August  24, 
1899,  Dr.  Crile  stated  that  he  had  operated  by  the  " blocking" 
method,  up  to  that  time,  on  7  patients,  i  of  these  being  a  case  of  am- 
putation at  the  shoulder-joint  anesthetized  by  "blocking"  the  brach- 
ial  plexus  above  the  clavicle.  Dr.  Crile's  first  case  of  amputation  of 
the  leg  was  reported  to  the  Ohio  State  Medical  Society  in  1897,  and 
excited  the  attention  of  that  body.  This  performance  is  one  of  the 
most  brilliant  and  useful  contributions  to  the  technic  of  regional  anes- 
thesia that  have  emanated  in  recent  years  from  an  American  surgeon. 

Since  the  first  successful  demonstration  of  these  methods  by 
Matas  and  Crile  they  have  been  used  repeatedly  by  other  operators 
and  are  now  no  longer  novelties. 

"The  effect  of  intraneural  injections  is  usually  and  promptly  felt, 
and  the  effect  is  almost  identical  with  that  following  the  complete 
section  of  a  mixed  nerve.  The  only  difference  between  this  and  com- 
plete anatomic  section  lies  in  the  remarkable  fact  that  the  voluntary 
control  of  the  parts  below  the  'blocked'  nerves  is  largely  retained,  so 
that  the  patient  can  materially  assist  the  surgeon  in  his  manipula- 
tions. All  pain  conduction,  all  thermal  sense  is  entirely  lost;  the 
muscular  sense  is  impaired,  but  the  deep  reflexes  are  not  lost;  common 
sensation,  tactile  sense,  is  profoundly  obtunded,  but  is  not  altogether 
abolished.  This  affinity  of  cocain  for  the  pain-conducting  and 
thermal  fibers  is  one  of  the  many  remarkable  features  of  its  marvelous 
anesthetic  action"  (Matas). 

In  some  unusual  cases  the  anesthesia  following  intraneural  in- 
jection has  been  retarded;  this  retardation  has  been  sometimes  so 
prolonged  that  on  more  than  one  occasion  I  have  felt  worried  at  the 
prospect  of  total  failure.  After  waiting  patiently  for  fifteen  and  in 
one  case  twenty  minutes,  the  characteristic  subjective  paresthesia  be- 
gan, and  in  a  few  seconds  thereafter  the  anesthesia  was  complete. 
Once  established,  the  anesthesia  will  remain  as  long  as  the  circulation 
is  arrested  by  the  constrictor,  but  in  places  where  constriction  is  not 
satisfactory,  as  at  the  groin  (anesthesia  of  the  anterior  crural)  and 
at  the  brachial  plexus,  the  nerves  will  remain  anesthetized  for  forty- 
five  minutes  to  an  hour,  if  a  i  per  cent,  novocain  or  a  4  per  cent, 
beta-eucain  solution  is  used  with  adrenalin. 

The  anesthesia  is  more  transitory  if  the  weaker  solutions  are  in- 


THE   UPPER   AND    LOWER   EXTREMITIES  23 1 

jected,  and  for  this  reason  a  i  per  cent,  novocain  or  0.4  per  cent, 
beta-eucain  should  be  preferred.  Should  the  anesthesia  begin  to  dis- 
appear before  the  completion  of  the  operation,  the  nerves  can  be  re- 
injected.  In  injecting  the  nerves  great  care  should  be  observed  to 
use  the  finest  needle,  and  to  employ  only  fresh  and  perfectly  sterile 
solutions.  The  fluids  must  be  introduced  into  the  center  of  the  nerve, 
with  the  needle  directed  parallel  to  the  nerve-fibers.  Very  few  drops 
will  usually  suffice  to  give  the  nerve  a  slight  fusiform  swelling  at  the 
point  of  injection,  which  is  characteristic  of  a  thorough  infiltration. 
Injections  made  in  this  manner  into  a  healthy  nerve  are  never  painful, 
provided  that  the  nerve  is  held  slack,  so  that  the  injection  can  be 
made  without  the  least  traction  upon  its  fibers.  Should  traction 
be  made  upon  the  nerve-trunk  or  tension  made  upon  its  fibers,  pain 
will  be  produced.  In  case  a  nerve  is  inflamed  from  the  extension  of  a 
surrounding  inflammation,  intraneural  injections  will  always  cause 
pain.  For  this  reason,  when  practising  regional  anesthesia,  the  nerve- 
trunks  should  be  injected  sufficiently  high  above  the  area  of  inflam- 
mation to  be  well  beyond  a  possible  lymphangitis  of  the  nerve-sheath. 
For  instance  if  it  be  necessary  to  amputate  a  finger,  and  the  inflamma- 
tion extend  well  up  toward  its  base,  it  would  be  preferable  to  inject 
the  nerves  above  the  wrist;  or  should  it  be  necessary  to  open  a  deep 
palmar  infection  or  resect  a  metacarpal  bone,  and  the  inflammation 
extend  to  or  above  the  wrist,  it  would  be  better  to  inject  the  nerves  at 
the  elbow. 

The  paraneural  injection  of  the  brachial  plexus  both  above  the 
clavicle  and  below  it  in  the  axilla,  as  has  been  recommended  and  prac- 
tised by  some  operators,  but  particularly  in  the  axilla,  is  a  far  too 
dangerous  procedure  to  find  a  place  in  the  operative  methods  of  con- 
servative operators. 

It  is  far  better,  safer,  and  surer,  as  well  as  quite  simple,  to  resort 
to  the  free  exposure  of  the  plexus  above  the  clavicle,  and  inject  each 
individual  nerve  by  the  intraneural  method,  as  first  advocated  by 
Crile.  These  nerves  are  too  large  to  be  readily  penetrated  in  effective 
quantities  by  the  anesthetic  fluid  with  any  degree  of  certainty,  and 
the  use  of  strong  solutions  at  these  points,  highly  vascular  and  close  to 
the  trunk,  in  any  effective  quantity  is  likely  to  prove  dangerous,  as 
absorption  is  active,  and  there  is  no  practicable  means  of  retaining  it 
in  situ  by  constriction. 

Aside  from  the  danger  in  the  solution  injected,  if  made  in  effective 
quantity  and  strength,  the  anatomy  of  this  region  should  be  sufficient 
to  deter  any  but  the  most  venturesome  from  this  practice. 


232 


LOCAL  ANESTHESIA 


external  maxillary  art. 


superficial  cervical  art.  X 

-,ctnd.br.  of  transverse  cervical  art. 
brachial  plexus 

transverse  cervical  art. 

'.  cerrtcat  arl. 

,''^       transverse  scapular  art. 
^       clavicle  X 
^^^      Mary  artery 


stibmfftfal 
superior  ""* 
of  sympathetic  trunk 
Omolirolaeus  IW-  *»'W 
superior  thyreoid  arl.  X 
Sternohyoidcu 

*"&.  cf  '"I" 
vasus  nerv 


axillary  vein 
phalic  vein  X 


Fig.  29. — The  nerves  and  arteries  of  the  deep  layers  of  the  neck  and  of  the  axilla. 
(Sixth  layer  of  neck,  deeper  layers  of  the  axilla.)  The  greater  portions  of  the  infra- 
hyoid  muscles  and  of  the  common  carotid  artery  have  been  removed;  the  clavicle  has 
been  disarticulated  at  the  sternoclavicular  joint  and  sawn  through  at  about  its  middle. 
The  pectoralis  major  and  minor  have  been  divided  and  the  deltoid  incised  along  the 
deltoid  branch  of  the  thoraco-acromial  artery.*  Accessory  sympathetic  ganglion. 
(Sobotta  and  McMurrich.) 

Above  the  clavicle  the  brachial  plexus  lies  well  to  the  base  of  the 
neck  on  the  scalenus  medius,  just  to  the  outer  border  of  the  scalenus 
anticus;  the  subclavian  artery  in  this  position  passes  behind  the 


THE  UPPER  AND  LOWER  EXTREMITIES 


233 


scalenus  with  the  plexus  above,  giving  off  in  this  neighborhood 
branches  of  large  size  (Fig.  29).  Many  veins  are  encountered  in  all 
directions,  and,  while  their  puncture  with  a  fine  needle  would  not  be  of 
much  consequence,  an  intravenous  injection  may  prove  a  more  serious 
matter. 

Below  the  clavicle  the  plexus  lies  to  the  outer  side  of  the  first  por- 
tion of  the  artery,  embraces  the  second  portion,  and  lies  somewhat 
more  widely  distributed  around  the  third.  The  vein  in  both  cases  is 
fairly  out  of  the  way. 

Notwithstanding  these  anatomic  arrangements,  paraneural  injec- 
tions have  been  made  in  both  positions.  The  Kulenkampff  method, 


Fig.  30. — Thorax  from  above,  after  Kulenkampff.  On  one  side  is  shown  the  posi- 
tion of  the  brachial  plexus  and  subclavian  artery  to  the  clavicle,  on  the  other  the  direc- 
tion the  needle  should  take  in  making  the  injection:  a,  Subclavian  vein;  b,  point  of 
attachment  of  anterior  scalenus  muscle;  c,  subclavian  artery;  d,  brachial  plexus;  e, 
point  of  attachment  of  scalenus  medius  muscle.  (From  Braun.) 

above  the  clavicle,  has  been  favorably  spoken  of  by  Braun,  and 
practiced  by  himself  and  many  others,  and  is  done  in  the  following 
manner:  That  portion  of  the  plexus  is  selected  for  injection  at  the 
point  where  it  passes  over  the  first  rib;  in  this  position  the  artery 
lies  below  and  on  the  inner  side,  the  clavicle  above  and  in  front,  the 
pleura  and  lung  beneath  (Fig.  30) . 

The  direction  of  the  brachial  plexus,  as  it  passes  under  the  clavicle, 
is  at  about  right  angles  to  the  lorig  axis  of  this  bone,  and  passes  under 
at  about  its  midpoint  in  the  erect  position  of  the  body;  for  this  reason, 
as  well  as  the  fact  that  in  this  position  the  clavicle  descends  slightly 


234  LOCAL   ANESTHESIA 

downward  and  forward,  thus  affording  a  better  exposure  of  the  field, 
it  is  advised  that  the  injection  be  made  in  the  sitting  position  (Fig. 
31).  The  method  of  procedure  is  as  follows: 

With  the  patient  sitting  erect,  the  finger  is  passed  over  the  mid- 
point of  the  clavicle  and  accurately  locates  the  artery  by  its  pulsations, 
the  skin  and  subcutaneous  tissue  is  now  lightly  infiltrated,  and  a  long 
fine  needle,  unattached  to  the  syringe,  are  passed  in  a  direction  down- 
ward, inward,  and  backward  from  the  midpoint  of  the  clavicle  in  such 
a  direction  that  it  aims  at  the  spinous  process  of  the  second  or  third 
dorsal  vertebra;  the  distance  to  be  penetrated  and  the  amount  of  fat 
vary,  but  it  is  usually  from  2  to  4  cm.,  the  plexus  lying  just  under 
the  deep  fascia.  When  the  plexus  is  reached  a  slight  radiating  pain 


Fig.    31. — Position    of  patient  for   Kulenkampff  brachial  plexus  injection.     (From 

Braun.) 

or  pares thesia  is  felt  down  the  branches  of  the  radial  or  median  nerve 
in  the  hand  or  fingers;  at  this  point  the  needle  is  held  stationary,  the 
syringe  attached,  and  the  injection  made.  The  object  in  not  attach- 
ing the  syringe  earlier  is  that  should  the  artery  be  entered  blood  will 
flow ;  should  this  occur  with  a  fine  needle  it  is  not  likely  to  be  of  much 
consequence,  the  needle  being  withdrawn  slightly,  and  the  point  di- 
rected a  little  more  laterally.  About  10  c.c.  of  a  2  per  cent,  novocain- 
suprarenin  solution  is  injected;  the  needle  is  now  slightly  withdrawn, 
and  an  additional  10  c.c.  injected  around  in  the  neighborhood,  to  be 
sure  to  reach  any  cord  of  the  plexus  that  the  first  injection  may  have 
missed. 

It  is  said  that  when  paresthesia  occurs,  which  indicates  that  the 


THE   UPPER   AND    LOWER   EXTREMITIES 


235 


plexus  has  been  reached,  anesthesia  is  certain,  and  usually  is  estab- 
lished in  from  one  to  three  minutes;  occasionally,  however,  it  may 


17 


Fig.  32. — Areas  of  distribution  of  cutaneous  nerves  (after  Toldt),  showing  effect  of 
Kulenkampff  plexus  anesthesia:  I,  Anesthesia;  +  +  ,  hyperesthesia;  D,  normal 
sensation;  i,  supraclavicular  nerves;  2,  circumflex;  3,  external  cutaneous;  4,  musculo- 
spiral;  5,  radial;  6,  musculocutaneous;  7,  median;  8,  radial  (terminal  branches);  9, 
lateral  cutaneous  from  second  intercostal;  10,  musculospiral;  n,  ulnar;  12,  internal 
cutaneous;  13,  plamar  branch  of  ulnar;  14,  dorsal  branch  of  ulnar;  15,  palmar  branch 
of  ulnar;  16,  digital  branches  of  ulnar;  17,  digital  branches  of  median.  (From 
Braun.) 


require  a  longer  delay,  from  ten  to  fifteen  minutes ;  failure  to  obtain 
anesthesia  by  this  time  usually  indicates  the  need  of  another  puncture, 
when  5  to  10  c.c.  of  a  4  per  cent,  solution  is  used  in  the  same  manner, 


236  LOCAL   ANESTHESIA 

except  that  the  paresthesia  in  the  extremity  does  not  occur  unless  the 
first  injection  has  gone  wide  of  the  mark;  should  the  first  injection 
fail,  the  second  is  not  near  so  likely  to  succeed  (Fig.  32). 

In  the  hands  of  Kulenkampff  and  his  associates,  who  injected  a 
large  number  of  cases  in  this  way,  very  few  failures  were  recorded. 

The  duration  of  the  anesthesia  is  from  one-half  hour  to  three  hours, 
and  is  associated  with  complete  muscular  relaxation  of  the  part. 

This  is  certainly  a  very  ingenious  and  simple  procedure  and  when 
properly  carried  out  would  ordinarily  be  supposed  to  be  free  from 
danger.  Clinical  reports,  however,  describe  a  great  many  by-  and 
after-  effects ;  the  most  common  is  a  transient  paralysis  of  the  phrenic 
nerve  on  the  injected  side.  This  has  been  demonstrated  by  x-ray  ex- 
aminations of  the  diaphragm  and  is  always  associated  with  some  dis- 
turbance of  respiration.  As  a  rule  this  phrenic  paralysis  clears  up  in  a 
few  hours  but  in  some  few  cases  it  has  persisted  for  several  days  and 
longer. 

Transient  paresis  of  the  sympathetic  of  the  neck,  with  contrac- 
tion of  the  pupil  and  the  orbicularis  oris,  occurs  quite  frequently,  occa- 
sionally associated  with  a  sinking  back  of  the  eye.  These  symptoms 
are  quite  transient. 

Less  frequently  paralytic  disturbances  have  been  noted  in  the 
arm  and  in  some  few  cases  these  injuries  have  been  more  or  less 
permanent. 

Reports  of  these  after-effects  must  make  the  conservative  oper- 
ator hesitate  to  employ  the  method.  It  is  readily  understood  how 
the  solution  can  diffuse  along  the  plexus  mesially  and  reach  the 
phrenic  and  sympathetic  nerves,  producing  a  temporary  effect,  but  in 
many  cases  where  the  effects  have  been  quite  lasting  it  has  no  doubt 
resulted  from  injury  by  the  needle,  as  no  after-effects  result  from  the 
many  intraneural  injections  of  nerve-trunks  where  the  nerves  are 
exposed  and  carefully  injected  without  trauma.  The  possibility  of 
a  small  percentage  of  failures,  as  with  all  paraneural  injections  of 
large  nerve-trunks,  is  another  objection  to  its  use.  In  view  of  the 
possible  paralysis  of  the  phrenic  nerve  it  would  seem  unnecessary  to 
caution  against  its  simultaneous  use  on  both  sides. 

Paraneural  Injection  Within  the  Axilla. — The  arm  is  abducted  to 
a  right  angle,  the  index-finger  of  one  hand  is  passed  up  on  the  outer 
side  of  the  fossa,  and  the  brachial  artery  located  and  slightly  displaced 
downward  and  inward ;  a  long  fine  needle  is  now  passed  over  the  tip 
of  the  finger  and  directed  up  in  the  long  axis  of  the  limb  until  well 
within  the  axilla,  when  the  injection  is  made;  the  precaution  should  be 


THE  UPPER  AND  LOWER  EXTREMITIES 


237 


followed  here,  as  elsewhere,  when  making  an  injection  in  the  neighbor- 
hood of  vessels  to  continuously  inject  the  solution  as  the  needle  is 
being  advanced;  in  this  way  the  vessels  may  be 
pushed  aside  and  their  puncture  avoided. 

The  needle  is  now  passed  behind  the 
artery  near  the  insertion  of  the  tendon 
the  latissimus  dorsi  to  reach  the 
posterior  cord  of  the  plexus,  and 

additional  injection  made 

Fig.  33.— Cuta^^»  ^^  at   f-his  point;  30  to  40 

neous  nerve  areas  of^^^^  B^k.  r 

the  upper  extremity  (an^^£  ^C.C.    of   a  2   per  cent, 

teriorview)  :  A,  Circumflex^^B         ::\>~^i  ^^^   nOVOCain-adren- 

C,  lesser    internal    cutaneous;  #^^lhkN  ^^.     alin  Solution 

internal  cutaneous;  E,  musculospiral; 
F,    musculocutaneous;    G     ulnar;    H, 
median.     (Campbell.) 


Fig.  34-— Cuta- 
neous nerve  areas  of 
upper  extremity   (poste- 
rior view) :  A ,  Supraclavicu- 
lar;  B,  circumflex;  C,  musculo- 
spiral;   D,  lesser   internal    cutane- 
ous; E,  internal   cutaneous;  F,  ulnar; 
G,  musculospiral.     (Campbell.) 

is  recommended  as  the  necessary  amount 
(containing  in  this  concentration  a  quantity 
of  the  drug  clearly  beyond  the  safe  limits) .  While 
the  supraclavicular  injection  will  find  a  place  in  our 
recognized  methods  of  procedure,  this  last  injection  within 
the  axilla  is,  to  say  the  least,  unsurgical,  and  is  not  to  be  recommended. 
The  location  and  distribution  of  the  nerve-supply  from  the  elbow 
down  should  be  carefully  studied  for  the  application  of  regional 
methods  of  anesthesia  to  these  parts,  particularly  the  cutaneous  dis- 
tribution, which  is  fairly  constant  (Figs.  33  and  34). 


238  LOCAL   ANESTHESIA 

NERVES  OF  THE  UPPER  EXTREMITY 

The  Musculocutaneous  (External  Cutaneous  Nerve). — The  cutane- 
ous portion  winds  around  the  outer  border  of  the  tendon  of  the  biceps, 
and,  piercing  the  deep  fascia,  becomes  superficial,  passing  behind  the 
median  cephalic  vein;  it  divides  opposite  the  elbow-joint  into  anterior 
and  posterior  branches. 

The  anterior  branch  descends  along  the  radial  side  of  the  fore- 
arm as  far  as  the  ball  of  the  thumb,  giving  off  cutaneous  branches 
to  this  region  back  of  the  wrist  and  carpus;  at  the  wrist- joint  it  is 
placed  in  front  of  the  radial  artery. 

The  posterior  branch  passes  along  the  back  part  of  the  radial 
side  of  the  forearm,  supplying  this  region  as  far  as  the  wrist. 

The  internal  cutaneous  nerve  pierces  the  deep  fascia  with  the  basilic 
vein  about  the  middle  of  the  arm,  and,  becoming  cutaneous,  divides 
into  anterior  and  posterior  branches.  The  anterior  branch  descends 
usually  in  front  of,  but  occasionally  behind,  the  median  basilic  vein, 
and  is  distributed  to  the  skin  on  the  anterior  part  of  the  ulnar  side  of 
the  forearm  as  far  as  the  wrist. 

The  posterior  branch  passes  obliquely  downward  and  backward 
over  or  in  front  of  the  internal  condyle  to  the  posterior  surface  of 
the  inner  side  of  the  arm,  and  is  distributed  to  the  skin  as  far  as  the 
wrist. 

The  lesser  internal  cutaneous  nerve  pierces  the  deep  fascia  on  the 
inner  side  of  the  brachial  artery  at  the  middle  of  the  arm,  and  is 
distributed  to  the  skin  on  the  inner  and  posterior  surface  as  far  as 
the  elbow. 

The  median  nerve,  at  the  bend  of  the  elbow,  lies  beneath  the  bi- 
cipital  fascia  to  the  inner  side  of  the  tendon  of  the  biceps,  separated 
from  it  by  the  brachial  artery.  It  passes  between  the  two  heads  of 
the  pronator  radii  teres,  and  it  is  deeply  situated  until  about  2  inches 
above  the  wrist,  when  it  becomes  superficial,  lying  between  the  ten- 
don of  the  flexor  sublimis  and  flexor  carpi  radialis  beneath  or  slightly 
to  the  ulnar  side  of  the  tendon  of  the  palmaris  longus,  and  follows 
this  course  into  the  hand. 

This  nerve  can  be  easily  reached  by  an  open  dissection  at  the  bend 
of  the  elbow  for  an  intraneural  injection,  or  by  passing  a  needle  be- 
neath the  tendon  of  the  palmaris  longus  above  the  wrist  for  a  para- 
neural  injection.  In  the  hand  this  nerve  supplies  the  superficial  mus- 
cles of  the  thumb,  two  outer  lumbricales,  both  sides  of  the  thumb, 
index,  and  middle  fingers,  and  radial  side  of  the  ring  finger  on  their 
palmar  aspect;  each  digital  nerve  opposite  the  base  of  the  first  pha- 


THE   UPPER   AND    LOWER  EXTREMITIES  239 

lanx  gives  off  a  dorsal  branch  which  joins  the  dorsal  branch  from  the 
radial,  and  runs  along  the  side  of  the  dorsum  of  the  finger  to  end  in 
the  skin  over  the  last  phalanx. 

The  ulnar  nerve,  at  the  bend  of  the  elbow,  lies  against  the  bone 
between  the  internal  condyle  and  olecranon,  and  is  easily  reached  in 
this  position  for  a  paraneural  injection  by  passing  the  needle  down 
to  it  through  the  skin.  In  the  forearm  the  nerve  is  deeply  situated, 
but  becomes  more  superficial  near  the  wrist,  lying  to  the  radial  side 
of  the  tendon  of  the  flexor  carpi  ulnaris  covered  by  the  skin  and  fas- 
cia, where  it  can  be  fairly  easily  reached  by  a  needle  for  paraneural 
injections. 

In  this  position  the  ulnar  artery  lies  to  the  radial  side  and  slightly 
more  superficial  than  the  nerve,  and  is  to  be  carefully  avoided  by 
keeping  the  needle  nearer  the  tendon  of  the  flexor  carpi  ulnaris;  the 
injection  should  be  made  sufficiently  free  to  permit  some  of  the  solu- 
tion reaching  the  artery  upon  which  the  palmar  cutaneous  branch, 
given  off  higher  up  in  the  arm,  descends  to  the  skin  of  the  palm. 

The  injection  should  be  made  about  2  inches  above  the  wrist,  to 
reach  also  the  dorsal  cutaneous  branch  which  is  given  off  in  this 
position,  and  curves  around  the  wrist  beneath  the  tendon  of  the 
flexor  carpi  ulnaris,  to  divide  into  branches  to  be  distributed  to  the 
inner  side  of  the  little  finger  and  adjoining  sides  of  the  little  and  ring 
fingers;  if  the  injection  is  made  too  low  these  branches  will  escape. 

The  nerve  continues  down  on  the  outer  side  of  the  tendon  of  the 
flexor  carpi  ulnaris  to  its  attachment  to  the  pisiform  bone,  and  im- 
mediately beyond  divides  into  superficial  and  deep  palmar  branches. 
The  superficial  branch  supplies  the  palmaris  brevis  and  skin  on  the 
inner  side  of  the  palm,  sending  digital  branches  to  the  inner  side  of 
the  little  and  adjoining  sides  of  the  little  and  ring  fingers.  The  deep 
palmar  branches  supply  the  deep  muscles  of  the  palm. 

The  musculospiral  nerve  appears  at  the  bend  of  the  elbow  after 
piercing  the  external  intermuscular  septum,  and  descending  between 
the  brachialis  anticus  and  supinator  longus  to  the  anterior  surface  of 
the  external  condyle,  where  it  divides  into  the  radial  and  posterior 
interosseous  nerves.  In  addition  to  these  terminal  branches  there 
are  three  cutaneous  branches:  an  internal  cutaneous,  which  is  dis- 
tributed to  the  arm  above  the  elbow,  and  is  not  of  much  concern  to 
us  here,  as  all  of  these  nerves  should  be  reached  by  blocking  the  brach- 
ial  plexus  above  the  clavicle. 

The  upper  and  smaller  branch  passes  to  the  front  of  the  elbow, 
lying  close  to  the  cephalic  vein,  and  is  distributed  to  the  skin  on  the 


240  LOCAL   ANESTHESIA 

anterior  surface  of  the  arm ;  some  fibers  from  this  nerve  may  descend 
below  the  elbow. 

The  lower  branch  is  the  more  important  to  us  here,  and  its  posi- 
tion should  be  borne  in  mind  in  all  nerve-blocking  operations  at  the 
elbow.  It  pierces  the  deep  fascia  below  the  insertion  of  the  deltoid, 
running  down  along  the  outer  side  of  the  arm  and  elbow,  then  along 
the  posterior  surface  of  the  radial  side  of  the  forearm  as  far  as  the 
wrist. 

The  radial  nerve  passes  down  the  arm  from  the  bend  of  the  elbow , 
lying  beneath  the  supinator  longus  to  the  outer  side  of  the  radial 
artery ;  about  3  inches  above  the  wrist  it  turns  outward,  passing  be- 
neath the  tendon  of  the  supinator  longus,  pierces  the  deep  fascia  on 
the  outer  border  of  the  forearm,  and  becomes  superficial.  In  this 
position  it  gives  off  its  digital  branches,  an  external  branch  which 
descends  to  the  radial  side  of  the  thumb,  and  an  internal  branch 
which  divides  into  three  digital  branches  to  supply  the  adjoining 
sides  of  the  thumb  and  index-finger,  index-  and  middle  fingers,  and 
the  adjacent  sides  of  the  middle  and  ring  fingers. 

This  nerve  can  best  be  reached  for  a  paraneural  injection  about 
2  inches  above  the  wrist  to  the"  outer  side  of  the  tendon  of  the  supina- 
tor longus,  making  the  injection  into  the  deep  fascia  and  carrying  it 
across  the  outer  border  of  the  forearm  for  about  an  inch,  to  insure 
reaching  all  branches  of  the  nerve. 

The  above  is  a  brief  review  of  the  nerve-supply  of  the  forearm 
and  hand  which  concerns  us  in  the  regional  anesthesia  of  these  parts. 
It  can  be  seen  from  a  study  of  the  points  at  which  these  nerves  are 
accessible,  the  opportunities  offered  for  blocking  them  either  by  direct 
exposure  and  intraneural  injection  or  through  paraneural  injection 
by  directing  the  needle  down  to  the  positions  in  which  the  nerves 
will  be  found.  But  the  possibilities  here  of  an  occasional  anomalous 
distribution  must  also  be  remembered.  For  all  operations  below 
the  elbow,  including  forearm,  wrist,  and  hand,  the  intraneural  method 
of  blocking  at  the  elbow  the  three  principal  nerve-trunks  in  this 
region — radial,  ulnar,  and  median — after  free  exposure  by  open  dis- 
section, as  first  practised  by  Dr.  Matas,  will  produce  a  perfect  anes- 
thesia of  all  distal  parts  where  the  technic  has  been  properly  carried 
out.  It  must,  however,  be  remembered  that,  in  addition  to  the 
three  above-mentioned  nerves,  the  skin  of  the  forearm  is  supplied 
by  the  internal  and  external  cutaneous  nerves,  and  if  account  is  not 
taken  of  these  in  making  the  injection  the  resulting  anesthesia  will 
be  imperfect  or  unsatisfactory. 


THE    UPPER   AND    LOWER   EXTREMITIES  241 

The  musculocutaneous  nerve  at  the  bend  of  the  elbow  passes 
behind  the  median  cephalic  vein,  then  divides  into  anterior  and  poste- 
rior branches.  The  anterior  branch  of  the  internal  cutaneous  passes 
in  front  of  or  behind  the  median  basilic  vein,  at  the  bend  of  the  elbow, 
its  posterior  branch  passing  over  the  inner  condyle. 

On  account  of  the  existence  and  position  of  the  above  cutaneous 
nerves  the  infiltration  done  at  the  bend  of  the  elbow  to  expose  the 
three  principal  nerve-trunks — radial,  ulnar,  and  median — should  be 
made  in  an  oblique  or  transverse  course,  and  not  vertical  over  the 
course  of  the  large  trunks,  unless  it  should  be  preferred  to  inject  the 
lateral  subcutaneous  tissue  by  a  separate  injection.  In  exposing  the 
radial  in  the  groove  between  the  brachialis  anticus  and  supinator 
longus,  if  the  infiltration  is  carried  in  toward  the  middle  line  in  the 
neighborhood  of  the  median  cephalic  vein,  it  will  include  in  the  anes- 
thetic atmosphere  the  external  cutaneous  nerve. 

It  must  also  be  remembered  in  injecting  the  radial  not  to  omit 
the  posterior  interosseous  nerve,  which  is  found  in  the  substance  of 
the  supinator  brevis.  These  two  nerves  are  best  exposed  by  dividing 
the  intermuscular  septum  between  the  supinator  longus  and  brachialis 
anticus  and  retracting  the  supinator  longus  when  the  nerves  are 
seen  in  the  depths  of  the  wound  or  lying  in  the  substance  of  the 
muscles.  The  infiltration  to  expose  the  median  nerve  will  probably 
reach  and  anesthetize  the  anterior  branch  of  the  internal  cutaneous 
which  lies  under  the  median  basilic  vein,  but,  to  be  sure  that  this 
nerve  as  well  as  the  posterior  branch  have  been  reached  by  the  solu- 
tion, it  is  advisable  to  inject  a  few  small  syringes  of  solution  sub- 
cutaneously  between  the  median  nerve  and  the  internal  condyle. 
The  ulnar  nerve  in  thin  and  emaciated  subjects,  where  it  can  be 
readily  felt,  need  not  be  directly  exposed,  but  can  be  injected  para- 
neurally,  but  where  overlaid  by  much  tissue  it  is  safer  and  more 
surgical  to  directly  expose  it.  In  discussing  this  particular  procedure 
Prof.  Matas,  in  his  report  on  "Local  and  Regional  Anesthesia" 
before  the  Louisiana  State  Med.  Soc.,  1900,  states  the  following: 

"Personally,  I  regard  the  open  intraneural  method  of  cocainiza- 
tion  of  the  three  nerves — musculospiral,  median,  and  ulnar — at  the 
bend  of  the  elbow  as  the  most  effective,  certain,  and  simple  means  of 
securing  total  anesthesia  of  the  hand,  wrist,  and  forearm. 

"It  is  a  strictly  anatomic  procedure  which  admits  of  no  guess- 
work, and  for  this  reason  is  not  likely  to  be  popularized  except  in  the 
clinics  of  surgical  specialists. 

"The  practicability  of  this  method  suggested  itself  to  me  in  1897, 


i  6 


242  LOCAL   ANESTHESIA 

but  no  opportunity  presented  itself  for  its  application  until  January, 
1898,  when  an  old  man,  aged  seventy-six,  applied  to  my  clinic  for 
the  relief  of  an  extensive  and  deep  epitheliomatous  ulcer,  which  in- 
volved a  large  part  of  the  dorsal  and  hypothenar  regions  of  the  right 
hand.  The  patient  was  profoundly  arteriosclerotic,  his  radials  were 
hard  and  rigid  as  a  pipe-stem,  and  his  heart  was  the  seat  of  loud  aortic 
and  mitral  murmurs,  which  indicated  advanced  valvular  lesions. 
He  was  a  decidedly  unfavorable  subject  for  general  anesthesia,  and 
I  decided  to  anesthetize  the  hand  by  the  direct  neuroregional 
method. 

"The  musculospiral,  the  median,  and  the  ulnar  were  readily  and 
painlessly  exposed  (under  infiltration  anesthesia,  Schleich  No.  i) 
by  separate  incisions,  made  over  the  region  of  the  individual  nerve- 
tracts,  where  they  are  most  superficial  at  the  bend  of  the  elbow; 
the  nerves  were  then  exposed,  and  each  injected  with  5  to  8  minims  of 
a  i  per  cent,  solution  of  cocain.  This  caused  a  slight  fusiform  swell- 
ing at  the  point  of  injection. 

"The  wounds  were  sutured,  but  the  threads  were  not  tied,  to 
provide  for  further  injection,  and  the  entire  region  was  protected  by 
a  carefully  applied  aseptic  dressing.  The  arm  was  then  exsanguinated 
by  elevation,  and  the  elastic  constrictor  was  applied  over  the  middle 
of  the  arm.  The  anesthesia  of  the  extremity  was  now  complete  from 
the  finger-nails  up  to  the  elbow.  We  were  then  able  to  extirpate  the 
growth  very  freely,  including  the  fourth  and  fifth  fingers  with  their 
metacarpals  and  the  corresponding  palmar  and  dorsal  aspects  of 
the  hand,  proceeding  throughout  with  all  the  freedom  that  is  per- 
mitted by  general  anesthesia.  After  completing  the  work  in  the  hand 
the  incision  at  the  elbow  was  closed  by  tying  the  knots  of  the  loose 
catgut  sutures,  which  had  been  purposely  left  untied  before  the 
constrictor  was  removed.  The  operation  was  in  this  way  not  only 
painless,  but  bloodless.  Before  the  operation  the  patient  was  given 
a  hypodermic,  consisting  of  Y±  gr.  morphin,  34o  gr.  strychnin,  and 
Koo  gr-  digitalin. 

"Since  the  first  operation  (January,  1898)  was  performed  the 
procedure  has  been  repeated  by  myself  several  times  and  once  by 
my  assistant,  Dr.  Larue.  In  all  these  cases  the  intervention  was 
necessitated  by  bone  lesions  of  either  the  hand,  wrist,  or  forearm. 

"In  all  of  these  cases  the  patients  were. able  to  walk  to  their  beds 
after  leaving  the  operating-table.  None  suffered  from  the  least  shock 
or  constitutional  disturbance,  and  in  none  were  the  postoperative 
sequelae  such  as  to  suggest  that  any  injury  had  been  done  by  cocainiza- 


THE   UPPER   AND   LOWER   EXTREMITIES  243 

tion  of  the  nerves.  All  the  small  wounds  made  to  expose  the  nerves 
healed  kindly  under  the  usual  aseptic  dressing.  In  all  of  these  cases 
the  anesthesia  of  the  regions  tributary  to  the  nerves  injected  con- 
tinued for  a  variable  period,  extending  from  ten  to  fifteen  minutes 
after  the  removal  of  the  constrictor. 

"In  view  of  the  practical  success  of  this  method  of  obtaining  com- 
plete insensibility  of  all  the  parts  below  the  elbow,  it  is  superfluous  to 
enumerate  or  discuss  all  the  operations  that  can  be  performed  in  this 
region  without  the  help  of  general  anesthesia.  It  is  evident  that  in 
absolutely  anesthetic  fields  all  operations  are  possible. 

"I  would  again  lay  stress  upon  the  fact  that  the  method  here 
described  is  a  regional  method,  in  which  the  anesthesia  is  obtained 
by  the  direct  infiltration  of  the  nerves  at  a  distance  from  the  field 
of  operation,  and  differs  from  all  other  methods  suggested  to  accom- 
plish the  same  regional  object  except  that  of  Dr.  Crile,  of  Cleveland, 
Ohio,  which  is  identical  in  principle  and  technic,  except  that  it  is 
applied  at  a  higher  level  by  injecting  the  brachial  plexus  in  the  supra- 
clavicular  space. 

"At  the  time  that  my  first  operation  was  performed  I  was  not 
aware  that  very  nearly  the  same  results  had  been  obtained  by  Reclus 
some  time  before  the  publication  of  his  remarkable  book,  'La  Cocaine 
en  Chirurgie/  in  1896.  Reclus'  operation  differs,  however,  from 
the  one  here  described  in  the  essential  fact  that  he  attacked  the  three 
nerves  at  the  elbow  by  subcutaneous  paraneural  injections.  He 
erroneously  attributes  the  suggestion  to  Krogius,  of  Helsingfors,  Fin- 
land, and  his  results,  though  apparently  satisfactory,  were  not 
sufficiently  encouraging  to  decide  him  to  continue  its  further  applica- 
tion. In  addition  to  his  doubts  as  to  the  general  reliability  of  this 
method,  he  fears  that  traumatic  neuritis  may  result  from  the  direct 
injection  of  the  nerves,  and  also  believes,  very  justly,  that  the  intro- 
duction of  the  needle  in  search  for  the  nerves  in  the  vascular  sheaths 
at  the  root  of  the  limb  is  fraught  with  too  much  risk  to  justify  the 
general  adoption  of  this  practice.  We  concur  in  these  criticisms,  as 
they  apply  to  the  subcutaneous  paraneural  method,  which  is  largely 
a  matter  of  approximation  and  guessing.  These  objections  do  not 
hold,  however,  with  the  open  intraneural  method,  in  which  the  nerve 
to  be  injected  is  directly  exposed  to  view. 

"As  to  the  possibility  of  traumatic  neuritis,  which  Reclus  fears,  I 
have  never  noticed  the  least  evidence  or  trace  of  it  in  the  many  cases 
in  which  I  have  had  an  opportunity  to  practice  this  method  in  various 
regions  of  the  body.  Le  Fort  ('Soc.  Centrale  de  Med.  du  Nord.,' 


244  LOCAL  ANESTHESIA 

October  27,  1899,  and  'Gaz.  des  Hopitaux/  November  25,  1899)  has 
also  more  recently  directed  attention  to  the  paraneural  regional 
method  and  applies  it  at  the  elbow  and  wrist,  just  as  Reclus,  Manz, 
and  Holscher  have  done.  He  refers  to  Desoutte's  experiments  with 
neural  anesthesia  in  horses  and  expresses  confidence  in  its  value.  He 
also  expresses  a  theoretic  fear  of  neuritis  from  trauma  of  the  nerves 
by  direct  injection,  but  this  fear,  as  I  have  stated,  is  unfounded.  I 
do  not  doubt  that  the  subcutaneous  paraneural  method  is  a  feasible 
procedure,  and  will  yield  satisfactory  results  in  emaciated,  fleshless 
patients,  in  whom  the  larger  nerve-trunks  are  almost  visible  under 
the  skin;  in  such  patients  there  should  be  no  difficulty  in  reaching 
the  immediate  vicinity  of  the  nerves,  or  the  nerves  themselves  for 
that  matter,  since  they  are  practically  exposed  to  view.  It  is  also 
in  just  such  patients  that  the  Schleich's  general  infiltration  anesthesia 
will  find  a  successful  application.  Not  long  since  Dr.  Gessner  re- 
ported a  case  of  amputation  of  the  arm  above  the  elbow  for  tuber- 
cular arthritis  of  the  elbow-joint,  in  which  the  anesthesia  was  ob- 
tained with  perfect  success  by  the  Schleich  infiltration  method. 
Schleich,  Reclus,  and  their  numerous  followers  have  reported  many 
cases  of  the  same  kind  (vide  among  other  recent  contributions). 

"'La  Nacose  et  1'anesthesie  locale  par  J.  Richbon  Kjamerund, 
Bull,  gen'l  de  Therap.,'  January  15  and  30,  1899;  and  T.  Wieker- 
hauser,  'Operationen  mit  Schleichscher  Analgesic,  Centralbl.  fur 
Chir.,'  October  21,  1899. 

"In  the  earlier  years  of  my  experience  with  cocain  I  also  per- 
formed an  amputation  of  the  arm  by  Coming's  infiltration  for  ad- 
vanced tubercular  arthritis  with  excellent  results ;  but  these  successes 
do  not  mean  that  Schleich's  infiltration  method  is  applicable  to  all 
cases ;  it  only  illustrates  the  advantage  to  be  derived  from  the  adop- 
tion of  the  various  methods  of  anesthesia  to  different  conditions." 

Dr.  Matas,  in  his  previously  mentioned  report,  in  writing  of  the 
hand  and  wrist,  states  the  following: 

"The  anesthesia  of  these  regions  is  obtained  by  any  one  of  three 
methods:  (i)  Direct  infiltration  (Schleich);  (2)  paraneural  infiltra- 
tion at  the  wrist  (Reclus,  Braun,  Manz,  Lefort) ;  (3)  regional  direct 
(open)  intraneural  infiltration  at  the  elbow  (Matas)."  To  these  we 
can  now  add  the  intravenous  method  of  Bier  and  intra-arterial 
anesthesia. 

"The  utility  of  the  infiltration  method  is  practically  limited  to 
fractional  areas  of  these  parts,  and  can  be  applied  successfully  in  the 
evacuation  of  purulent  collections,  palmar  abscesses,  the  removal  of 


THE   UPPER  AND   LOWER   EXTREMITIES  245 

well-defined  tumors,  warts,  epitheliomata,  etc.,  foreign  bodies,  the 
extirpation  of  ganglions,  etc.  It  has  also  proved  sufficient  in  my 
practice,  as  in  that  of  others,  for  the  amputation  of  one  or  two  fingers 
with  their  metacarpals,  but  in  all  these  the  effectiveness  of  the  in- 
filtration will  be  very  materially  increased  by  a  knowledge  of  the  dis- 
tribution of  the  cutaneous  and  deeper  nerves  supplying  the  area  of 
operation.  Thus  in  resecting  or  disarticulating  the  metacarpals,  the 
infiltration  is  not  only  carried  into  the  entire  periphery  of  the  bone, 
including  the  periosteum,  but  the  deep,  adjoining  interosseous  nerves 
must  likewise  be  enveloped  in  a  cocain  atmosphere.  When  the 
injuries  or  lesions  are  such  that  the  operation  is  likely  to  be  extensive, 
irregular,  or  ill-defined,  as,  for  instance,  when  several  digits  with  their 
metacarpals  are  to  be  amputated  with  a  part  of  the  palmar  tissues, 
a  recourse  to  the  neuroregional  method  at  a  higher  level  is  preferable, 
if  not  absolutely  necessary,  from  the  point  of  view  of  effectiveness 
and  simplicity.  In  anesthetizing  the  hand  and  wrist  in  its  totality, 
the  radial,  ulnar,  and  median  nerves  can  be  anesthetized  by  injecting 
the  anesthetizing  fluid  deeply  into  the  perineural  tissues  along  the 
well-known  anatomic  paths  of  these  nerves  in  the  lower  forearm,  just 
above  the  wrist,  where  they  are  known  to  be  most  superficial.  This 
procedure  was  first  described  and  practiced  by  O.  Manz  (Kraske's 
clinic;  'Centralbl.  f.  Chirurg./  1898,  No.  7),  by  Holscher  ('Muench. 
Med.  Wochenschr.,'  February  21, 1899),  and  by  F.  Berndt  ('Muench. 
Med.  Wochenschr.,'  1899,  No.  27),  and  in  their  hands  has  yielded  some 
fairly  good  results.  Holcher  and  Berndt,  following  Oberst  and  Braun, 
apply  an  elastic  constrictor  i  or  2  inches  above  the  wrist,  and  inject 
20  c.c.  of  a  2  per  cent,  cocain  solution,  distributed  in  the  region  of  the 
three  nerve-trunks,  and  wait  fifteen  minutes,  when  the  insensibility 
of  the  entire  hand  will  follow.  But  the  paraneural  method  applied 
in  this  blind  subcutaneous  fashion  is,  as  Manz  himself  admits,  an  un- 
certain and  unsatisfactory  procedure  at  best,  and  it  is  not  likely  to  find 
many  adherents." 

THE  FINGERS  AND  HAND 

In  the  practice  of  regional  anesthesia  of  the  hand  and  fingers  we 
have  many  opportunities  for  blocking  the  nerve-trunks  just  above 
the  wrist  by  taking  advantage  of  their  superficial  position  and  ex- 
posing them  by  dissection  for  intraneural  injection,  or  through  para- 
neural  injections  by  passing  the  needle  through  the  skin  down  to  the 
points  where  these  nerves  are  to  be  found.  The  following  experi- 
ments, made  by  Prof.  Heinrich  Braun,  of  Zwichau,  and  given  in  his 


246  LOCAL   ANESTHESIA 

book  on  "Die  Lokal  Anasthesie,"  illustrates  the  possibilities  of  its 
use  here: 

"Experiment  i  (June  18,  1898,  Dr.  B.).  Firm  constriction  of  the  arm.  Injection  of 
i  c.c.  of  i  per  cent,  tropococain  solution  3  cm.  above  the  wrist  under  the  tendon  of  the 
palmaris  longus  (Fig.  35).  The  constricting  rubber  band  was  now  sufficiently  loosened 
to  permit  a  marked  stasis  hyperemia  of  the  arm.  Fifteen  minutes  after  the  injection 
complete  anesthesia  of  the  distribution  of  the  median  nerve,  as  well  as  paralysis  of  the 
short  muscles  of  the  thumb,  was  produced.  The  anesthesia  remained  fifteen  minutes 
after  the  removal  of  the  constrictor.  t , 

"Experiment  2  (May  14,  1902,  Dr.  B.).  One-half  cubic  centimeter  of  2  per  cent, 
cocain  solution  was  injected  at  10.45,  4  cm-  above  the  wrist  under  the  tendon  of  the 
palmaris  longus;  the  arm  was  not  constricted;  at  10.47  a  feeling  of  tickling  and  warmth 
in  the  first,  second,  third,  and  fourth  fingers  and  palm  of  the  hand;  10.55,  complete  anes- 
thesia on  the  flexor  surface  of  the  thumb,  second  and  third  fingers,  and  the  radial  side 
of  the  fourth  finger,  in  the  palm  of  the  hand  a  very  marked  depression  of  the  sensibility 
in  the  entire  nerve  territory,  with  a  paresis  of  the  thumb  muscles;  11.25,  sensation 
returned. 

"Experiment  3  (Oct.  10,  1902,  medical  student,  B.).  11.55,  injection  of  i  c.c.  of  0.5 
per  cent,  cocain  solution  with  3  drops  adrenalin  around  the  median  nerve  above  the 
wrist.  The  arm  was  not  constricted.  After  fifteen  minutes  the  sensibility,  as  indicated 
in  Fig.  36,  Nos.  I  and  II,  almost  completely  disappeared;  on  the  ball  of  the  thumb,  in  the 
palm  of  the  hand,  and  on  the  flexor  surfaces  of  the  thumb  and  index-finger  completely 
disappeared.  There  was  very  pronounced  paralysis  of  the  short  muscles  of  the  thumb, 
and  the  skin  over  the  distribution  of  the  median  nerve  was  hyperemic,  red,  and  showed 
increased  temperature,  while  the  skin  over  the  neighboring  ulna  distribution  remained 
normal.  The  sensibility  returned  about  2  o'clock,  two  hours  after  the  injection." 

By  taking  advantage  of  the  superficial  position  of  the  radial 
nerve  just  above  the  wrist,  where  it  passes  beneath  the  tendon  of  the 
supinator  longus  on  the  outer  border  of  the  arm,  and  making  the  in- 
jection in  a  transverse  manner  at  this  point  beneath  the  skin  and 
superficial  veins,  an  anesthesia  of  its  peripheral  branches  is  obtained, 
as  illustrated  by  the  following  experiments: 

"Experiment  4.  After  constriction  of  the  arm  i%  c.c.  of  0.5  per  cent,  cocain  solu- 
tion was  injected  in  the  above  manner.  After  five  minutes  anesthesia  appeared,  as 
indicated  in  Fig.  36,  Nos.  Ill  and  IV. 

"Experiment  5  (May  13,  1899,  Dr.  B.).  The  same  experiment  with  2  c.c.  of  0.5  per 
cent,  tropocain  solution  with  constriction  of  the  arm  resulted  in  an  anesthesia  of  about 
similar  extent. 

"Experiment  6.  Forms  the  continuations  of  experiment  No.  3  on  the  same  hand, 
where  previously  the  median  nerve  had  been  blocked,  i  c.c.  of  0.5  per  cent,  cocain  solu- 
tion, with  the  addition  of  3  drops  adrenalin  solution  (1:1000)  was  now  injected  on  the 
radial  nerve  above  the  wrist.  Fifteen  minutes  later  the  hand,  as  indicated  in  Fig.  36, 
Nos.  V  and  VI,  was  completely  insensible  and  remained  so  for  about  four  hours." 

As  mentioned  by  Braun  in  commenting  upon  this  experiment,  it  is 

not  likely  to  be  of  much  value  alone  except  for  very  limited  superficial 

operations,  but  when  combined  with  a  simultaneous  injection  of  the 

median  nerve  it  is  a  simple  and  effective  means  of  anesthetizing  the 

* 


THE   UPPER   AND    LOWER   EXTREMITIES 


247 


entire  radial  side  of  the  hand.  Higher  up  in  the  forearm,  at  the  junc- 
tion of  the  middle  and  lower  third  on  the  outer  border,  where  the 
intermuscular  septum  divides  the  flexor  from  extensor  muscles,  the 
radial  nerve  is  also  fairly  accessible,  and  may  be  successfully  blocked 
at  this  point  by  passing  the  needle  vertically  inward  beneath  the 
supinator  longus.  The  following  experiment  by  Dr.  Braun  illustrates 
the  results  obtained: 

"  Experiment  7  (May  2,  1902,  Dr.  D.).  Twelve  o'clock,  an  injection  of  i  c.c.  of  2  per 
cent,  cocain  solution  in  the  above-described  way,  the  needle  had  exactly  met  the  nerve- 
trunk,  as  indicated  by  the  radiating  paresthesia.  No  constriction.  Immediately  after 
the  injection  occurred  a  marked  radiating  paresthesia  and  sense  of  warmth  in  the  thumb. 
12.10,  complete  regional  anesthesia  of  the  nerve;  anesthesia  of  the  skin  is  indicated,  as 
in  Fig.  37,  No.  II.  Motor  paralysis  of  the  radial.  After  forty  minutes  sensibility  and 
motility  returned. 


Minterosseus  dors 


Af.alnaris 


i/i  a  j        -    i  <sf  N.medianus 

M  flexor ulnsns     •#         A,     .     , 

M.palm.  long. 

Fig-  35. — Cross-section  through  forearm  three  fingers-breadth  above  pisiform  bone 

(From  Braun.) 

The  ulnar  nerve  is  accessible,  either  for  exposure  by  dissection  and 
intraneural  injection  or  for  paraneural  injection,  above  the  wrist- 
joint,  preferably  three  or  four  fingers'  breadth  above  to  insure  reach- 
ing the  posterior  branch,  which  may  be  given  off  this  high  up.  In 
this  position  the  nerve  lies  between  the  tendon  of  the  flexor  carpi 
ulnaris  and  the  ulnar,  as  shown  in  Fig.  35,  and  is  best  reached  for 
paraneural  injections  by  introducing  the  needle  from  the  ulnar  side 
between  the  tendon  and  the  bone  in  the  direction  indicated  by  the 
arrow.  It  is  rather  unsafe  and  inadvisable  to  attempt  to  reach  it 
from  in  front  (except  by  dissection)  on  account  of  the  proximity  of 
the  ulnar  vessels,  which  here  lie  slightly  more  superficial  than  the  nerve 
and  slightly  to  the  radial  side.  Figure  36,  VII  and  VIII,  indicate 
the  extent  of  the  resulting  anesthesia  after  an  injection  of  i  c.c.  of 
a  0.5  per  cent,  cocain  solution  with  3  drops  of  adrenalin  (i  :  1000)  as 
practiced  by  Braun  in  the  above-mentioned  way.  It  may,  however, 


248 


LOCAL   ANESTHESIA 


be  easier  and  preferable,  instead  of  injecting  the  nerve  at  this  point 
to  reach  it  back  of  the  internal  condyle.  In  thin  subjects,  where 
the  nerve  can  be  readily  felt,  a  paraneural  injection  may  be  under- 
taken by  first  locating  the  nerve  between  the  thumb  and  finger  of 
one  hand  while  making  the  injection  with  the  other;  the  inferior 
profunda  artery,  which  lies  in  this  position,  is  more  deeply  situated 
in  the  muscle  just  over  the  bone.  The  following  experiments  by 


Fig.  36. — Resulting  areas  of  anesthesia  of  hand  and  fingers  from  subcutaneous  and 
paraneural    injections.     (From    Braun.) 

Braun  illustrates  the  result  obtained,  while  Experiment  9  is  a  para- 
neural injection  of  the  ulnar  and  median  nerves  above  the  wrist: 

"Experiment  8  (May  13,  1902,  Dr.  L.).  12.50  o'clock,  injection  of  i  c.c.  of  2  per 
cent,  cocain  solution  in  the  previously  mentioned  way.  No  constriction.  Immediately 
paresthesia  and  sense  of  warmth  as  far  as  the  ends  of  the  fourth  and  fifth  fingers.  After 
six  minutes  complete  regional  anesthesia  of  the  skin  occurred,  as  indicated  in  Fig. 
37,  I.  Sensibility  returned  fifty  minutes  after  the  injection. 

"  Experiment  9  (Dec.  9,  1902,  medical  student).  One  cubic  centimeter  of  i  per  cent, 
cocain  solution  with  3  drops  of  adrenalin  solution  was  injected  three  fingers'  breadth 
above  the  wrist  on  .the  ulnar  and  median  nerves.  After  twenty  minutes  anesthesia 
appeared  in  the  territory,  as  indicated  in  Fig.  36,  IX  and  X.  The  sensibility  returned 
after  four  hours  in  the  ulnar  territory  and  after  five  hours  in  the  median." 


THE   UPPER   AND    LOWER  EXTREMITIES 


249 


Experiment  10  represents  the  results  of  a  linear  injection  made 
subcutaneously  from  the  region  of  the  radial  artery  across  the  back  of 
the  wrist  to  the  pisiform  bone. 

"Experiment  10  (Feb.  10,  1899,  Dr.  B.).  Three  cubic  centimeters  of  i  per  cent, 
cocain  solution  was  injected  in  the  previously  mentioned  way  in  the  arm  after  constric- 
tion. After  five  minutes  anesthesia  appeared  in  the  territory,  as  indicated  in  Fig.  36,  XI 
and  XII.  Twenty  minutes  after  removal  of  the  constriction  sensibility  returned. 

"Experiment  n.  Five  cubic  centimeters  of  2  per  cent,  cocain  solution  was  injected 
in  a  line  across  the  extensor  surface  of  the  forearm,  6  cm.  above  the  head  of  the  ulna. 


Fig.  37. — Resulting  areas  of  anesthesia  of  arm,  hand,  and  fingers  from  subcutaneous  and 
paraneural  injections.     (From  Braun.) 

The  arm  was  not  constricted.  After  fifteen  minutes  anesthesia  appeared,  as  indicated  in 
Fig.  37,  III.  A  transverse  subcutaneous  injection  was  made  on  the  flexor  side  of  the 
wrist,  which  resulted  in  an  anesthetic  field  being  produced,  as  shown  in  Fig.  37,  IV.  It  is 
clear  from  a  study  of  the  picture  that  only  the  more  superficial  cutaneous  branches  in 
the  immediate  neighborhood  were  effected,  and  none  of  the  deeper  branches." 

The  result  of  a  circular  subcutaneous  injection  above  the  middle 
of  the  forearm  is  shown  by  Braun  in  Fig.  37,  VI;  8  c.c.  of  a  0.5  per 
cent,  tropacocain  solution  was  used,  the  forearm  being  constricted. 

The  anesthesia,  as  indicated  in  the  shaded  area,  was  complete  in 
ten  minutes.  The  following  experiments  are  also  of  interest.  In 


250  LOCAL   ANESTHESIA 

commenting  upon  experiment  No.  15,  Braun  states  that  he  has  often 
employed  this  method  for  opening  and  excising  an  inflamed  bursa 
over  the  olecranon: 

"Experiment  13  (Dr.  B.).  Four  cubic  centimeters  of  0.5  per  cent,  cocain  solution 
with  8  drops  of  adrenalin  solution,  i:  1000,  was  injected  in  a  continuous  subcutaneous 
line,  which  began  posteriorly  over  the  olecranon  and  extended  laterally  over  the  external 
condyle  to  the  middle  of  the  biceps  tendon  in  front.  It  required  twenty-five  minutes  for 
anesthesia  to  be  produced,  as  indicated  in  Fig.  38,  III.  The  anesthesia  then  remained 
several  hours. 

"Experiment  14  (Dr.  P.).  Four  cubic  centimeters  of  0.5  per  cent,  cocain  solution 
with  8  drops  of  adrenalin,  i :  1000,  was  injected  in  a  subcutaneous  line,  which  began  over 
the  olecranon  posteriorly  and  extended  over  the  internal  condyle  to  the  middle  of  the 
biceps  tendon.  After  thirty  minutes  the  anesthetic  area,  as  indicated  in  Fig.  38,  IV, 


Fig.  38. — Resulting  areas  of  anesthesia  from  subcutaneous  infiltration   of   forearm. 

(From  Braun.) 

appeared.  In  the  lower  half  of  the  forearm,  as  in  the  preceding  experiment,  the  anes- 
thesia was  not  complete. 

"Experiment  15  (Dec.  12,  1902,  Dr.  L.).  Four  cubic  centimeters  of  0.5  per  cent, 
cocain  solution  with  8  drops  of  adrenalin  solution,  i :  1000,  was  injected  in  a  subcutaneous 
line  beginning  over  the  internal  condyle  and  extending  in  a  curve  over  the  posterior 
surface  of  the  arm  and  ending  over  the  belly  of  the  supinator  longus  at  the  external 
condyle.  After  fifteen  minutes  the  anesthetic  area,as  indicated  in  Fig. 38,  II,  was  com- 
plete. Deep  needle  sticks  over  the  olecranon  and  over  the  posterior  surface  of  the  ulna 
showed  that  the  periosteum  was  also  insensible. 

"Experiment  16  (Nov.  i,  1902,  Dr.  B.).  Four  cubic  centimeters  of  0.5  per  cent. 
cocain  solution  with  8  drops  of  adrenalin,  i  :  1000,  was  injected  subcutaneously  in  a  line 
which  began  over  the  internal  condyle  and  extended  deeply  across  the  bend  of  the  elbow 
to  terminate  over  the  belly  of  the  supinator  longus.  The  veins  were  avoided  without 
difficulty,  passing  the  needle  under  them.  After  thirty  minutes  the  area,  as  indicated 


THE    UPPER   AND    LOWER    EXTREMITIES  251 

in  Fig.  38, 1,  also  almost  the  entire  flexor  surface  of  the  forearm  and  a  part  of  the  extensor 
surface  had  become  anesthetic.  The  injection  was  made  at  12  o'clock,  and  about  4 
o'clock  in  the  afternoon  sensation  returned." 

Anesthesia  of  a  part  of  a  finger  can  be  obtained  by  direct  local 
infiltration ;  more  often  the  anesthesia  of  an  entire  finger  is  necessary, 
especially  in  inflammatory  affections  (bone  felons,  panaritium,  teno- 
synovitis,  traumatism,  foreign  bodies,  etc.).  In  all  such  cases  the 
paraneural  infiltration  method  applied  at  the  root  of  the  fingers  will 
yield  perfect  results.  This  is  the  method  which  we  have  continu-, 
ously  followed  in  our  practice.  If,  for  example,  it  is  a  bone  felon 
that  we  wish  to  open,  the  skin  of  the  root  of  the  finger,  a  little  above 
the  level  of  the  palmar  web,  is  infiltrated  on  the  dorsal  side  (Fig.  39); 
a  fine  hypodermic  needle  is  used  for  infiltration,  and  a  wheal  of  intra- 
cuticular  edema  serves  as  the  starting-point  from  which  a  circle  of 


Fig.  39. — Cross-section  of  finger:  a,  Flexor  tendon;  b,  bone;  c,  extensor  tendon;  i,  and 
2,  points  of  entrance  of  needle  to  reach  dorsal  and  palmar  nerves.     (From  Braun.) 

anesthesia  is  carried  around  the  base  of  the  digit.  After  this  has 
been  done,  the  needle  is  driven  in  painlessly  through  the  infiltrated 
skin  into  the  lateral  aspect  of  the  finger  in  search  of  the  digital  nerves, 
which  lie  on  each  side  of  the  phalanx  in  close  proximity  to  the  blood- 
vessels but  superficial  to  them.  The  palmar  nerves  are  the  larger 
and  more  important,  and  for  operations  on  the  palmar  aspect  of  the 
last  phalanx  their  anesthesia  will  prove  sufficient,  but  elsewhere  it 
is  better  to  anesthetise  all  four  nerves  as  they  overlap  each  other  in 
their  distribution. 

The  palmar  nerves  are  found  just  beneath  the  lateral  slope  of  the 
palmar  surface  about  %  inch  beneath  the  skin,  and  the  dorsal  nerves 
in  a  similar  position  dorsally.  A  few  drops  (5  to  10)  of  strong  solu- 
tion of  novocain  (i  per  cent.)  are  injected  into  the  paraneural  regions 
so  as  to  create  an  anesthetic  atmosphere  around  the  nerves. 

The  arm  is  now  raised  and  the  finger  is  exsanguinated  by  gravity, 


252  LOCAL  ANESTHESIA 

after  which  the  circulation  is  arrested  by  applying  a  narrow  elastic 
band  around  the  finger,  just  above  (centrad  of)  the  ring  of  infiltra- 
tion. In  a  few  minutes  the  finger  will  be  "numb,"  and  will  bear 
any  operation  that  may  be  required  in  any  part  of  the  digit. 

"In  inflammatory  affections  the  action  of  the  anesthetic  will  be 
intensified  by  injecting  the  solution  warm  in  order  to  favor  its  diffu- 
sion (Corning,  Tito-Costa,  Hackenbuch).  After  the  constrictor  had 
been  applied  and  the  limb  has  assumed  a  cadaveric  appearance,  the 
application  of  ice-cold  water,  or  ethyl  chlorid  spray,  for  a  few  minutes 
to  the  finger  will  hasten  and  greatly  intensify  the  anesthetic  effect. 
This  is  particularly  true  of  acute  inflammatory  conditions,  which  are 
the  most  rebellious  to  local  anesthetic  influences.  If  the  anesthesia 
is  retarded  we  should  be  in  no  hurry  to  add  more  anesthetic.  The 
best  plan  is  to  relax  the  constrictor,  allow  the  circulation  to  return, 
and  diffuse  the  anesthetic  for  half  a  minute,  and  again  exsanguinate 
and  constrict  the  digit.  The  elastic  constrictor  combined  with  ex- 
sanguination  is  not  only  valuable  in  prolonging  the  anesthesia  in- 
definitely, but  it  helps  to  intensify  it  as  well.  In  fact,  it  is  possible 
by  simple  exsanguination  and  prolonged  elastic  compression  at  the 
root  of  the  finger  and  limbs  to  produce  a  degree  of  anesthesia  which 
is  itself  compatible  with  the  painless  performance  of  small  and  super- 
ficial operations.  (This  fact,  long  ago  utilized  by  James  Moore, 
1784,  and  by  Hunter,  has  been  especially  insisted  upon  in  recent 
times  by  Corning,  Kauffman,  Kummer,  and  every  surgeon  who  has 
had  experience  with  it.)  The  paraneural  method  which  we  have 
described  is  simply  a  regional  application  of  Coming's  principles 
(1885)"  (Matas). 

"In  Germany  it  is  known  as  Oberst's  method,  the  only  difference 
between  his  method  and  Oberst's  consisting  in  the  fact  that  Oberst 
applies  the  constrictor  first;  it  is  also  referred  to  by  some  writers  as 
Kummer's  (1886)  and  Kroguis'  (1896)  method,  but  the  principles 
of  the  method  are  really  of  American  origin,  and  began  with  the  ex- 
periments of  Hall  and  Halsted  (1884)  and  Corning  (1885). 

"An  effort  has  been  made  in  some  quarters  to  establish  an  an- 
tagonism between  Schleich's  method  and  the  paraneural  regional 
method,  as  here  described,  but  this,  as  Briegleb  and  others  have 
shown,  is  not  really  true.  Schleich's  infiltration  method,  as  applied 
to  the  anesthesia  of  a  finger  or  toe,  is  a  regional  method,  since  he 
completely  edematizes  the  circumference  of  the  finger  at  its  base  and 
thus  controls  the  entire  nerve-supply  of  the  digit.  The  regional 
method  simply  accomplishes  the  same  results  in  a  more  economic 


THE  UPPER  AND  LOWER  EXTREMITIES  253 

manner,  the  solutions  being  more  concentrated  in  percentage  and 
injected  in  direction  of  the  nerve-tracts,  thus  avoiding  the  complete 
edematization  of  the  tissue  that  is  necessary  in  using  Schleich's 
weaker  solutions"  (Matas). 

The  regional  anesthesia  of  a  finger  by  the  Schleich  method  is 
quite  easily  carried  out.  It  is  preferable  to  make  the  first  puncture 
on  the  dorsal  aspect  as  here  the  skin  is  less  sensitive  than  on  the 
palmar  surface  and  it  is  more  convenient  to  work  from  the  dorsal 
surface  forward.  This  first  puncture  can  be  made  through  a  frozen 
point  from  an  ethyl  chloride  spray  or  the  skin  can  be  pinched  up. 
The  needle  is  passed  around  the  finger  subcutaneously  injecting 
rather  freely  as  it  is  advanced,  first  in  one  direction  and  then  in  the 
other.  The  needle  is  withdrawn  and  redirected  further  around  until 


Fig.  40. — Areas  of  digital  anesthesia  resulting  from  transverse  subcutaneous  infil- 
tration on  dorsal  and  palmar  surfaces.  Compare  with  nerve  distribution,  shown  in 
Fig.  41.  (From  Braun.) 

the  entire  circumference  has  been  fully  edematised.  It  is  well  now 
to  elevate  the  hand  to  permit  exsanguination  when  a  stationer's  elas- 
tic or  tape  is  tied  around  the  finger  proximal  to  the  injected  area. 
Massage  and  manipulation  of  the  infiltrated  area  hasten  its  diffu- 
sion in  all  directions.  It  is  usually  necessary  to  use  about  %  ounce 
of  solution  for  the  thorough  anesthesia  of  a  finger  in  this  way  and 
to  wait  about  five  minutes  for  its  full  effect  to  become  established. 

Figure  40  illustrates  the  results  of  a  subcutaneous  injection  made 
on  the  palmar  surface  of  the  middle  finger  and  the  dorsal  surface  of 
the  index-fingers,  in  each  case  making  the  injection  deep  enough  to 
reach  the  corresponding  digital  nerves.  It  illustrates  beautifully  the 
distribution  of  the  digital  nerves,  the  palmar  digital  nerves  supplying 
the  entire  palmar  surface  and  the  dorsal  surface  of  the  last  phalanx, 
the  dorsal  digital  nerves  reaching  only  as  far  as  the  middle  phalanx. 


254 


LOCAL   ANESTHESIA 


nervus  digitalis  dorsalis 

arteria  digitalis 
dorsalis 


art  trio  digitalis/  '" 
roininiinis 


Fig.  41.  —  A  lateral  view  of  the  nerves  and  vessels  of  the  index-finger.     (Sobotta  and 

McMurrich.) 


Fig.  42. — Points  of  injection  and  lines  of  infiltration  in  operating  upon  fingers  and 

hand.     (From  Braun.) 


Fig.  43. — Points  of  injections  and  lines  of  infiltration  for  anesthetizing  two  or  more 

fingers.     (From  Braun.) 


THE    UPPER    AND    LOWER    EXTREMITIES 


255 


The  disparity  in  the  two  shaded  areas  represents  the  overlapping  of 
the  fields  of  the  two  nerves  (Fig.  41). 

A  study  of  Figs.  42-46  will  suggest  the  further  application  of 
regional  methods  to  the  base  of  one  or  more  fingers  and  parts  of  the 


Fig.  44. — Points  of  injections  and  lines  of  infiltration  for  resecting  part  of  hand. 

(From  Braun.) 

hand,  the  large  dots  indicating  the  points  at  which  the  nerves  are  to 
be  reached  by  subcutaneous  injection  for  paraneural  infiltration,  the 
dotted  lines  marking  the  course  for  intradermal  infiltration.  As  the 


Fig.  45. — Points  of  injections  and  lines  of  infiltration  for  anesthetizing  abscess  at  base 

of  fingers.     (From  Braun.) 

nerves  in  the  hand  are  all  small  it  is  practicable  to  use  Solution  No.  i 
throughout,  but,  if  preferred,  the  paraneural  or  deep  injections  can 
be  made  with  0.5  per  cent,  novocain  solution,  using  10  to  20  minims 
about  each  nerve.  It  is  evident  that  in  extensive  resections  of  the 


256 


LOCAL   ANESTHESIA 


hand  it  is  preferable  to  resort  to  regional  anesthesia  at  the  elbow  or 
above  the  wrist,  rather  than  resort  to  too  extensive  infiltrations  in 
this  region. 

It  may,  however,  be  desirable  to  use  methods  of  infiltration  for 
securing  regional  anesthesia,  as  these  methods  are  always  simple  and 
quickly  carried  out  and  when  properly  done,  thoroughly  effective. 

For  illustration  take  the  dorsum  of  the  hand  as  shown  in  Fig.  44, 
in  which  we  will  say  there  has  been  an  injury  which  will  require  the 
amputation  of  all  four  fingers  at  the  metacarpo-phalangeal  joint.  A 
point  is  selected  about  the  middle  of  the  dorsum  and  an  intradermal 
wheal  established  with  a  fine  needle.  The  long  fine  needle  and  large 


Fig.  46. — Points  of  injections  and  lines  of  infiltration  for  resecting  digits  or  part  of  hand. 

(From  Braun.) 

syringe  is  now  used  throughout;  the  needle  entered  through  this 
wheal  is  directed  subcutaneously,  first  towards  one  side  of  the  hand 
and  then  the  other,  injecting  freely  as  it  is  advanced.  The  needle 
is  now  directed  down  through  each  interosseous  space  injecting  as  it 
is  advanced,  all  the  way  to  the  skin  of  the  palm.  The  needle  is  now 
entered  in  either  one  or  the  other  end  of  the  subcutaneous  infiltration 
made  along  the  dorsum  which  is  continued  subcutaneously  across 
the  palmar  surface,  thus  encircling  the  hand.  This  establishes  a  wall 
of  anesthesia  through  the  hand  from  skin  to  skin  and  all  nerve-fibers 
passing  through  it  are  effectively  blocked.  It  is  usually  necessary 
to  wait  about  five  minutes  for  full  anesthesia.  As  a  rule  no  constric- 
tor is  needed  as  the  adrenalin  in  the  solution  acts  as  an  effective 


THE    UPPER   AND    LOWER    EXTREMITIES  257 

hemostatic,  and  the  pressure  from  the  infiltration  is  also  a  material 
hemostatic  aid.  About  2^2  or  3  ounces  of  solution  are  usually  needed 
for  this  operation.  -> 

By  following  the  above  method  a  smaller  section  of  the  hand  can 
be  similarly  blocked  off  as  suggested  by  Figs.  42-44. 

While  this  plan  is  always  quick,  simple  and  effective,  it  has  its 
objections  and  should  not  be  used  in  diseased  conditions  where  the 
vitality  of  the  tissues  is  already  compromised,  as  it  may  be  followed 
by  sloughing,  but  will  find  its  most  useful  field  in  injuries  to  healthy 
young  adults.  In  diseased  conditions  it  is  preferable  to  block  the 
nerves  higher  up. 

THE  LOWER  EXTREMITY 

"What  has  been  said  of  the  upper  extremity  may  be,  in  a  great 
measure,  repeated  in  regard  to  the  lower  limbs.  The  general  prin- 
ciples and  methods  are  the  same,  except  that  they  vary  in  their  topo- 
graphic application.  The  infiltration,  the  paraneural  infiltration, 
and  the  regional  (open)  intraneural  methods  can  all  be  utilized  with 
advantage  according  to  the  regions  involved  and  the  local  and  con- 
stitutional indications  furnished  by  the  patients  themselves. 

"The  infiltration  method  with  weak  solutions,  according  to 
Schleich,  with  or  without  constriction,  and  the  mixed  infiltration- 
neural  methods  are  alone  able  to  meet  a  vast  number  of  indications. 
The  surgery  of  the  toes  and  of  their  metatarsals  and  limited  areas 
of  the  soft  parts,  including  the  ligations  of  all  vessels  of  the  lower 
extremity  from  the  external  iliac  (R.  N.  Hartley,  Leeds,  1895)  to  the 
dorsalis  pedis,  can  be  made  subservient  to  the  infiltration  method. 
In  our  own  practice  we  have  notes  of  cases  of  ligation  of  the  super- 
ficial femoral  at  Scarpa's  triangle,  of  the  anterior  and  posterior  tibial 
(in  one  case  a  traumatic  aneurysm  of  the  middle  third),  and  of  the 
anterior  tibial,  in  which  these  operations  were  performed  with  infil- 
tration on  the  Corning  plan.  We  have  repeatedly  extirpated  the 
varicose  saphenous  vein  from  the  groin  to  the  knee,  and  performed 
Sonnenburg's  operation  for  varicose  veins  by  ligation  and  partial 
excision  of  the  internal  and  external  saphenous  with  simple  infiltra- 
tion anesthesia.  Infiltration  is  also  sufficient  for  opening  abscesses, 
including  large,  diffuse,  purulent  collections;  in  draining  joints;  in 
the  extraction  of  foreign  bodies;  in  the  removal  of  tumors,  and  in  the 
excision  of  ulcers  of  moderate  size.  It  is  particularly  valuable  in 
making  all  variety  of  exploratory  incisions  to  clear  up  doubtful  diag- 
nosis, etc.  As  early  as  1888  I  was  able  to  extirpate  a  subperiosteal 


258  LOCAL  ANESTHESIA 

sarcoma  of  the  femur  in  a  very  thin  subject.  Josiah  Roberts,  of  New 
York  was  able  to  perform  a  femoral  supracondyloid  osteotomy  (Mac- 
ewen's  operation  for  genu  valgum)  in  a  boy  four  years  old,  and  an 
excision  of  the  hip  (the  head  of  the  femur  being  removed  below  the 
great  trochanter)  in  a  child  six  years  of  age  by  the  same  procedure. 
These  operations  were  performed  by  Coming's  method  as  early  as 
1885,  a  5  per  cent,  cocain  solution  being  used  ('New  York  Med. 
Jour.,'  October  24,  1885).  Varick,  by  utilizing  the  same  technic, 
successfully  amputated  the  thigh  in  1886  ('New  York  Med.  Jour.,' 
vol.  x,  No.  in). 

"Trapani  was  also  one  of  the  first  to  report  an  amputation  of  the 
thigh  by  Schleich's  method  (vide  Alessandri's  reports  on  anesthesia 
to  the  Italian  Surgical  Society,  Transactions  for  1897).  Schleich 
and  his  followers,  Rhodes  (of  California),  Cowan,  and  others,  were 
among  the  earliest  to  report  instances  of  amputation  of  the  leg  by 
simple  infiltration,  and  Wilkerhauser  ('  Operationen  mit  Schleichscher 
Analgesie,'  abstract,  'Centralbl.  f.  Chir./  October  21,  1899,  No.  42) 
reports  18  extensive  bone  operations  out  of  a  list  of  113  major  opera- 
tions done  by  this  method,  in  which  the  sections  of  the  thigh  and  leg 
bones  were  required.  All  of  these  earlier  reports,  which  can  now  be 
multiplied  many  hundred  times,  simply  confirm  the  statement  pre- 
viously made  that  it  is  necessary  to  exercise  judgment  in  the  adap- 
tation of  the  various  methods  of  local  and  regional  anesthesia  to 
special  conditions.  The  operator  should  not  be  wedded  to  any  single 
method,  but  knowing  the  capabilities  of  each  can  select  his  technic 
and,  at  times,  obtain  surprising  results  with  a  method  that  would 
appear  to  the  inexperienced  as  theoretically  inadequate  to  meet  the 
demands  of  the  case"  (Matas). 

"But,  in  spite  of  the  numerous  interventions  on  the  lower  limbs 
which  have  been  obtained  by  simple  infiltrations  with  the  Corning 
or  Schleich  methods,  it  must  be  recognized  that  these  successes  have 
been  (with  the  notable  exception  of  the  toes)  more  conspicuous  by 
their  rarity  than  by  their  frequency.  They  simply  illustrate  what 
can  be  done  with  the  method  in  exceptionally  favorable  conditions, 
both  as  regard  to  the  morale  of  the  patient  and  the  favorable  ana- 
tomic condition  of  the  parts.  This  is  particularly  true  of  all  extensive 
operations  involving  the  skeleton  of  the  foot,  leg,  and  thigh  in  robust, 
fleshy  subjects.  In  this  class  of  patients  local  anesthesia  is,  as  a  rule, 
inadequate,  and  when  an  excision  of  a  large  joint  (the  ankle  or  knee), 
or  when  a  large  sequestrotomy,  osteotomy,  or  an  amputation  is  con- 
templated, a  method  more  positive  and  reliable  is  required  to  accom- 


THE   UPPER   AND    LOWER   EXTREMITIES  259 

plish  the  intervention  with  that  freedom  of  action  that  can  only  come 
from  absolute  analgesia.  It  is  precisely  under  such  circumstances, 
and  when  the  contra-indications  to  general  anesthesia  are  positive, 
that  the  regional  intraneural  method  can  be  confidently  appealed 
to"  (Matas). 

The  Nerve-supply  of  the  Lower  Extremity. — The  external  cut- 
aneous nerve  emerges  from  the  pelvis,  close  to  the  anterior  superior 
spine  of  the  ilium,  beneath  Pouparts'  ligament.  In  thin  subjects  it 
is  easily  reached  in  this  position  or  just  below  it  by  a  paraneural 
injection.  The  anterior  branch  of  this  nerve  emerges  from  beneath 
the  fascia  lata,  about  4  inches  below  Poupart's  ligament,  and  be- 
comes subcutaneous,  supplying  the  skin  on  the  anterior  and  outer 
side  of  the  leg  as  far  as  the  knee. 

The  posterior  branch  curves  backward  and  supplies  the  skin  on 
the  outer  and  posterior  aspects  of  the  thigh  as  far  as  the  middle  of 
the  limb. 

Dr.  Hugh  Young  was  one  of  the  first  to  utilize  paraneural  injec- 
tions of  this  nerve  to  obtain  skin-grafts  from  the  outer  side  of  the 
thigh. 

The  obturator  nerve  enters  the  thigh  through  the  upper  part  of 
the  obturator  foramen  and  divides  into  anterior  and  posterior 
branches,  which  are  separated  from  each  other  by  fibers  of  the  ob- 
turator externus  and  adductor  brevis  muscles.  The  anterior  branch 
passes  down  behind  the  pectineus  and  adductor  longus  and  communi- 
cates with  the  internal  cutaneous  and  internal  saphenous  nerves, 
forming  a  plexus  around  the  femoral  artery,  which  descends  on  this 
vessel  to  near  the  knee-joint;  occasionally  this  communication  fur- 
nishes a  cutaneous  branch  to  the  thigh  and  leg;  when  this  occurs  this 
nerve  passes  beneath  the  adductor  longus  and  sartorius  muscles  and 
becomes  superficial  at  the  inner  side  of  the  knee,  communicating  with 
the  long  saphenous  nerve,  and  is  distributed  to  the  inner  side  of  the 
leg  as  low  as  its  middle.  When  this  branch  is  absent  its  place  is 
supplied  by  the  internal  cutaneous.  The  posterior  branch  supplies 
the  adductor  muscles,  and  sends  a  branch  to  the  knee-joint  which 
descends  upon  the  popliteal  artery  to  the  back  of  the  joint. 

The  deep  position  of  the  obturator  nerve  where  it  enters  the  thigh, 
and  its  occasional  contribution  to  the  cutaneous  nerve-supply  of  the 
leg,  makes  this  nerve  often  a  troublesome  factor  in  the  regional  anes- 
thesia of  the  lower  extremity. 

The  anterior  crural  nerve  emerges  from  beneath  Poupart's  liga- 
ment, lying  on  the  outer  side  of  the  femoral  artery;  it  immediately 


260  LOCAL   ANESTHESIA 

divides  into  an  anterior  and  posterior  set  of  branches,  which  are  sep- 
arated by  the  external  circumflex  vessels. 

The  middle  cutaneous,  from  the  anterior  division  of  the  crural, 
becomes  superficial  about  3  inches  below  Poupart's  ligament  by  pier- 
cing the  fascia  lata;  it  divides  into  two  branches,  which  descend  on  the 
front  of  the  thigh  supplying  the  skin  as  far  down  as  the  knee. 

The  internal  cutaneous  nerve,  from  the  anterior  division  of  the 
crural,  passes  obliquely  across  the  upper  part  of  the  sheath  of  the 
femoral  artery,  and  divides  in  front  or  at  the  inner  side  of  that  vessel 
into  anterior  and  posterior  branches.  The  anterior  branch  passes 
down  on  the  sartorius  muscle  and  perforates  the  deep  fascia  at  the 
lower  third  of  the  thigh,  and  is  distributed  to  the  skin  of  this  region 
and  the  inner,  anterior,  and  outer  surfaces  of  the  knee.  The  pos- 
terior or  internal  branch  pierces  the  fascia  lata  on  the  inner  side  of 
the  knee  in  front  of  the  sartorius  tendon,  and  is  distributed  to  the 
skin  on  the  inner  side  of  the  leg. 

The  internal  or  long  saphenous  nerve,  from  the  posterior  division 
of  the  anterior  crural,  approaches  the  femoral  artery  beneath  the 
sartorius  muscle,  lying  first  in  front  and  then  on  the  inner  side  of 
this  vessel;  continuing  down  with  it  in  Hunter's  canal,  it  becomes 
superficial  by  piercing  the  deep  fascia  on  the.  inner  side  of  the  knee 
between  the  tendons  of  the  sartorius  and  gracilis  muscles;  it  then 
descends  along  the  inner  side  of  the  leg  in  company  with  the  internal 
saphenous  vein,  lying  just  behind  the  inner  border  of  the  tibia,  dis- 
tributing branches  to  the  inner  and  anterior  aspects  of  the  leg,  and 
terminates  by  passing  in  front  of  the  internal  malleolus,  to  be  dis- 
tributed to  the  skin  on  the  inner  side  of  the  foot  as  far  forward  as  the 
great  toe. 

The  small  sciatic  nerve  descends  beneath  the  pyriformis  muscles 
with  the  great  sciatic,  lying  slightly  to  the  inner  side  of  the  latter;  the 
perineal  and  pudendal  branches  curve  upward  to  these  regions,  while 
the  femoral  cutaneous  branches  pass  down  the  back  of  the  thigh  to 
supply  the  skin  as  far  down  as  the  back  of  the  leg. 

The  great  sciatic  nerve  descends  into  the  thigh  beneath  the  pyri« 
formis  muscle,  lying  midway  between  the  tuberosity  of  the  ischium 
and  the  great  trochanter,  and  passes  down  to  about  its  lower  third, 
where  it  divides  into  internal  and  external  popliteal  nerves;  this 
division  may,  however,  take  place  at  any  part  of  its  course  from  the 
pelvis  down,  and  should  be  borne  in  mind  in  injecting  this  nerve  high 
up  to  insure  getting  both  trunks. 

The  internal  popliteal,  the  larger  of  the  two  branches,  descends 


THE  UPPER  AND  LOWER  EXTREMITIES  261 

along  the  back  part  of  the  thigh  and  middle  of  the  popliteal  space, 
lying  first  on  the  outer  side  of  the  artery,  then  crossing  behind  it  to  its 
inner  side  and  passing  with  it  beneath  the  arch  of  the  soleus,  when 
it  becomes  the  posterior  tibial. 

The  posterior  tibial  nerve,  deeply  situated  above,  becomes  more 
superficial  lower  down,  where  it  is  covered  by  the  skin  and  fascia;  in 
the  lower  third  of  the  leg  it  lies  just  internal  to  the  margin  of  the 
tendo  achillis;  in  the  interval,  between  the  malleolus  and  the  heel,  it 
lies  external  to  the  artery  against  the  posterior  surface  of  the  tibia 
and  about  i  cm.  internal  to  the  tendo  achillis;  in  this  position  it  is 
readily  accessible  for  paraneural  injections.  Lower  down  in  this 
space  the  nerve  divides  into  internal  and  external  plantar  branches. 
The  internal  branch  supplies  the  sole  and  inner  side  of  the  foot  and 
gives  off  digital  branches  to  the  inner  side  of  the  big  toe,  adjoining 
sides  of  the  big  and  second  toe,  second  and  third  and  fourth  toes.  It 
will  be  observed  that  the  distribution  of  this  nerve  is  almost  identical 
to  the  distribution  of  the  median  in  the  hand,  the  digital  branches 
giving  off  dorsal  cutaneous  branches  at  the  base  of  the  toes  in  the 
same  manner  as  occurs  in  the  hand. 

The  external  plantar  nerve  supplies  the  outer  side  of  the  foot, 
little  toe,  and  adjoining  side  of  the  fourth  toe,  together  with  deep 
muscles  of  the  foot,  closely  corresponding  to  the  distribution  of  the 
ulnar  in  the  hand. 

The  external  popliteal  or  peroneal  nerve  descends  close  along  the 
inner  margin  of  the  biceps  tendon  on  the  outer  side  of  the  popliteal 
space;  it  then  passes  between  the  tendon  of  the  biceps  and  outer 
head  of  the  gastrocnemius  muscle  and  curves  around  the  head  of  the 
fibula,  where  it  can  be  readily  felt,  and  is  again  accessible  for  ex- 
posure or  for  paraneural  injection;  it  then  descends  into  the  substance 
of  the  peroneus  muscles.  The  cutaneous  branches  from  this  nerve 
supply  the  skin  of  the  back  part  and  outer  side  of  the  leg  as  far  down 
as  the  heel.  In  the  substance  of  the  peroneal  muscles  this  nerve 
divides  into  anterior  tibial  and  musculocutaneous  branches. 

The  anterior  tibial  nerae  is  deeply  situated  in  the  upper  part  of  its 
course,  but  becomes  more  superficial  near  the  ankle,  lying  to  the 
outer  side  of  the  dorsalis  pedis  artery  and  between  the  extensor  pro- 
prius  hallucis  and  the  extensor  longus  digitorum;  at  this  point,  just 
above  the  annular  ligaments,  it  is  fairly  accessible  for  exposure  and 
direct  injection,  or  for  paraneural  injection  after  locating  the  dorsalis 
pedis  pulse  by  passing  the  needle  down  to  the  deep  fascia  just  external 
to  the  artery;  however,  it  would  be  preferable  in  making  a  para- 


262 


LOCAL  ANESTHESIA 


Fig.  47. — Cutaneous  nerve-supply  of 
the  lower  extremity  (anterior  view):  A, 
Genitocrural;  B,  ilio-inguinal;  C,  external 
cutaneous;  D,  middle  cutaneous;  E,  inter- 
nal cutaneous;  F,  lateral  cutaneous  of 
peroneal;  G,  internal  saphenous;  H,  ex- 
ternal saphenous;  7,  musculocutaneous; 
J,  external  plantar;  K,  internal  plantar; 
L,  anterior  tibial.  (Campbell.) 


Fig.  48. — Cutaneous  nerve-supply  of 
the  lower  extremity  (posterior  view):  A, 
Small  sciatic;  B,  internal  cutaneous;  C, 
external  cutaneous;  D,  lateral  cutaneous; 
E,  internal  saphenous ;  F,  external  saph- 
enous; G,  musculocutaneous;  H,  internal 
calcaneus.  (Campbell.) 


THE    UPPER    AND    LOWER   EXTREMITIES  263 

neural  injection  to  do  so  higher  up,  where  the  peroneal  nerve  winds 
around  the  head  of  the  fibula,  thus  reaching  the  anterior  tibial  and 
muscular  cutaneous  distribution.  At  the  ankle-joint  the  nerve 
divides  into  an  internal  and  an  external  or  tarsal  branch.  The  in- 
ternal branches  supply  the  adjoining  sides  of  the  great  and  second 
toes.  The  external  branch  supplies  the  adjoining  sides  of  the  second, 
third,  and  fourth  toes  and  extensor  brevis  muscles. 

The  musculocutaneous  nerve  becomes  superficial  at  the  lower 
third  of  the  leg  by  passing  forward  between  the  peronei  muscles 
and  extensor  longus  digitorum;  in  this  position  it  can  be  reached  by 
a  subcutaneous  injection,  made  across  the  lower  portion  of  the  leg 
at  this  point,  over  the  tendons  of  the  above  muscles.  As  the  nerve 
descends  it  divides  into  two  branches,  an  internal,  which  passes 
over  the  front  of  the  ankle-joint  and  supplies  the  inner  side  and  dor- 
sum  of  the  foot,  inner  side  of  the  great  toe,  and  adjoining  sides  of 
the  second  and  third  toes.  The  external  branch  supplies  the  skin 
on  the  outer  side  of  the  foot  and  ankle,  and  the  adjoining  sides  of 
the  third,  fourth,  and  fifth  toes  (Figs.  47,  48). 

A  study  of  the  above  nerve-supply,  with  an  observance  of  the 
points  at  which  the  nerve-trunks  and  their  principal  branches  are 
accessible,  will  suggest  many  opportunities  for  the  practice  of  regional 
anesthesia.  The  following  operative  procedures  are  a  fairly  thorough 
review  of  the  surgical  possibilities. 

SCARPA'S  TRIANGLE  and  the  inguinal  region  receive  their 
nerve-supply  from  a  variety  of  sources  which  are  not  capable  of  being 
dealt  with  collectively  by  regional  methods,  consequently,  all  opera- 
tive procedures  here  should  be  done  under  infiltration,  from  the 
simple  incising  of  a  suppurative  bubo  to  the  removal  of  the  entire 
superficial  group  of  glands.  Where  the  deep  group  is  involved, 
requiring  dissections  beneath  the  fascia  lata,  a  general  anesthetic 
should  if  possible  be  used. 

In  operating  here  it  is  preferable  to  complete  the  entire  infiltra- 
tion before  making  the  incision^  as  it  is  difficult  to  anesthetize  the  dif- 
ferent planes  of  tissue  after  they  have  been  divided,  as  the  solution 
runs  out  as  fast  as  injected.  The  infiltration  had  best  be  done  on  the 
Hackenbruch  plan,  by  first  encircling  the  mass  by  a  line  of  intrader- 
mal  anesthesia;  the  needle  is  then  passed  from  this  line  into  the  deeper 
tissues,  all  around  and  under  the  mass  of  glands,  thus  completely 
enclosing  them  within  a  wall  of  anesthesia  (Figs.  19-49).  Solution 
No.  i  and  a  few  drops  of  adrenalin  to  the  ounce  is  used;  after  a  few 
minutes'  delay  allowed  for  thorough  saturation  of  the  tissues  the 


264 


LOCAL   ANESTHESIA 


operation  may  be  begun,  and  should  be  entirely  painless.  Where  the 
deep  glands  are  involved,  and  it  is  necessary  to  go  below  the  fascia 
lata,  the  different  tissues  should  be  infiltrated  as  the  operation  ad- 
vances, but  this  procedure  here  may  sometimes  prove  difficult.  Care 
should  be  observed  to  bear  in  mind  the  position  of  the  vessels,  and 
when  infiltrating  in  a  doubtful  region  to  make  the  injection  only 
when  advancing  or  withdrawing  the  needle. 

Other  tumors  of  this  region  may  be  removed  in  the  same  way. 


Fig.  49. — Shows  method  of  infiltrating  base  of  bubo  area  by  passing  needle  obliquely 
downward  and  inward  after  embracing  area  within  circle  of  cutaneous  anesthesia. 

The  removal  of  skin-grafts  is  quite  easily  performed  from  the  an- 
tero-external  aspect  of  the  thigh,  the  usually  selected  site,  either  by 
direct  intradermal  infiltration  of  the  entire  area,  from  which  the 
grafts  are  to  be  removed  (this  intradermal  edematization  of  the  skin 
greatly  facilitates  their  removal  without  apparently  affecting  the 
vitality  of  the  grafts),  or  by  a  pareneural  injection  of  the  external 
cutaneous  nerve,  where  it  emerges  from  beneath  Poupart's  ligament 
close  to  the  anterior  superior  spine,  as  first  practised  by  Dr.  Young  of 
Johns  Hopkins.  For  this  injection  the  needle  is  best  entered  from  the 
outer  side  and  penetrated  to  a  sufficient  depth  to  reach  beneath  the 
fascia  lata,  under  which  it  is  advanced,  depositing  2  drams  of  about  a 


THE  UPPER  AND  LOWER  EXTREMITIES 


265 


0.5  per  cent,  solution  of  novocain  in  the  recognized  position  of  the 
nerve.  Anesthesia  should  set  in  after  a  few  minutes,  and  be  suffi- 
ciently extensive  to  allow  of  a  fairly  liberal  removal  of  tissue. 

Varicose  Veins  of  Leg. — In  the  removal  of  varicose  veins  of  the 
leg,  the  operation  which  the  author  prefers  is  the  removal  of  the  en- 
tire vein  with  such  of  its  tributaries  as  seem  necessary,  from  the 
saphenous  opening  above  to  the  ankle  below. 

After  trying  many  methods  for  producing  anesthesia,  the  follow- 
ing plan  has  been  found  the  most  satisfactory. 

Usually  four  points  are  selected  for  making  the  injections,  which 
are  the  areas  through  which  the  incisions  will  be  made;  one  just  below 
the  saphenous  opening  in  the  fascia  lata,  one  slightly  above  the 
knee,  one  just  below  the  knee,  and  one  just  above  the  ankle  (see 
Fig.  50).  At  each  of  these  points  a  transverse  area  of  anesthesia  is 


'/) 'surface 


in  wheat 'and 
area  of  infiltration 


Vein 
FIG.  50. — Removal  of  various  veins  of  leg.    The  smaller  illustration  shows  the  detail. 

established  running  across  the  leg  at  right  angles.  This  infiltration 
is  done  in  the  same  methodical  manner  at  each  point.  Very  weak 
solutions  are  sufficient  for  this  work,  either  0.25  per  cent,  novocain  or 
0.20  per  cent,  eucain;  usually  8  ounces  are  required,  to  which  is  added 
20  drops  of  adrenalin  solution  i  :  1000.  All  four  areas  are  infiltrated 
before  the  operation  is  begun;  this  is  quickly  done  by  pursuing  the  fol- 
lowing plan.  With  the  small  syringe  and  fine  needle,  an  intradermal 
wheal  is  first  produced  in  the  center  of  each  of  the  four  areas  to  be 
infiltrated;  this  point  should  be  about  over  the  saphenous  vein.  The 
small  syringe  is  now  discarded  and  the  large  syringe  and  long  needle 
used  throughout.  Starting  above  at  the  wheal  near  the  saphenous 
opening,  the  needle  is  directed  subcutaneously  close  under  the  skin 
at  right  angles  to  the  axis  of  the  leg,  injecting  as  the  needle  is  ad- 
vanced for  a  distance  of  about  2  inches.  The  needle  is  partly  with- 


266  LOCAL   ANESTHESIA 

drawn  and  redirected  in  the  opposite  direction,  which  is  similarly 
injected. 

Partially  withdrawing  the  needle  again,  it  is  directed  at  a  slight 
angle  to  the  first  injection  and  passed  down  nearer  to  the  deep  fascia 
for  a  distance  of  about  2  inches;  always  injecting  steadily  when  the 
needle  is  being  advanced.  The  opposite  side  is  treated  similarly. 
Two  deep  injections  are  now  made  down  to  or  slightly  below  the  deep 
fascia,  one  on  each  side  of  the  position  of  the  vein.  During  these 
several  injections,  the  needle  is  not  withdrawn  from  the  skin,  the 
angle  being  changed  by  partially  withdrawing  it,  and  the  syringe 
detached  from  time  to  time  for  refilling.  Each  of  the  four  areas  for 
infiltration  is  treated  similarly,  using  about  2  ounces  of  solution  at 
each  point;  about  8  ounces  in  all,  slightly  more  for  very  stout  cases 
and  slightly  less  for  thin  ones. 

By  completing  the  infiltration  of  all  four  areas  before  the  opera- 
tion is  begun,  the  solution  is  allowed  ample  time  to  thoroughly  satu- 
rate the  tissues,  producing  the  maximum  degree  of  anesthesia  and 
diffusing  outward  toward  the  skin,  rendering  it  unnecessary  for  direct 
infiltration  here.  This  methodical  method  of  procedure  is  very 
quickly  done  and  saves  much  unnecessary  loss  of  time. 

By  beginning  the  anesthesia  above  and  progressively  working 
down  the  leg,  many  of  the  cutaneous  nerves  which  reach  the  lower 
parts  are  effectively  blocked  by  the  upper  injections  and  brings  each 
succeeding  area  of  injection  somewhat  under  the  influence  of  the 
injection  above.  Whereas,  if  the  opposite  order  of  procedure  were 
followed,  we  would  constantly  be  encountering  fibers  from  the  same 
nerve  in  a  sensitive  state. 

My  method  of  operating  has  some  advantages  and  is  particularly 
suited  to  local  anesthesia.  It  consists  essentially  in  enucleating  the 
vein  from  the  surrounding  tissue  by  the  use  of  the  finger,  which  is 
much  more  certain  of  removing  the  entire  vein  than  an  enucleator 
which  often  breaks  it  off,  particularly  if  diseased  and  friable.  An 
incision  is  made  through  the  upper  anesthetized  area  just  below  the 
saphenous  opening  and  the  vein  secured,  ligated  proximally  and 
divided,  a  stout  forcep  securing  the  distal  end.  By  traction  on  this 
f creep,  the  vein  is  held  taut  and  its  course  well  outlined;  the  finger  is 
now  worked  down  circumferentially  around  it,  separating  it  from  the 
surrounding  tissue,  any  branches  that  are  encountered  are  either 
broken  off  if  small,  or  by  locating  them  with  the  finger,  a  bistoury  is 
passed  down  alongside  the  finger  and  they  are  divided.  After  reach- 
ing as  far  down  as  can  be  readily  done  from  the  upper  opening,  the 


THE    UPPER   AND    LOWER   EXTREMITIES  267 

area  next  below  is  incised,  by  traction  on  the  vein  above  its  exact 
position  is  readily  made  out,  but  if  not  quickly  located,  a  long  probe 
is  passed  down  through  the  lumen  and  can  be  readily  palpated 
through  the  tissues  and  unnecessary  dissection  avoided.  The  proc- 
ess of  enucleation  is  similarly  continued  from  this  point  down  to  the 
ankle.  The  entire  procedure  is  quickly  carried  out  with  little  trauma 
to  the  tissues. 

THE  HIP  AND  THIGH 

"Regional  anesthesia,  in  amputation  of  the  middle  third  of  the 
thigh,  was  first  accomplished  by  Crile  in  1899  ('Cleveland  Medical 
Gazette,'  July  i,  1899,  vol.  xiv),  and  by  Berndt  (Gritti's  osteoplastic 
amputation)  ('Muench.  Med.  Wochenschr.,'  189*9,  No.  27),  the  former 
by  the  intraneural  and  the  latter  by  the  paraneural  methods.  I 
know  of  no  case  in  which  the  disarticulation  of  the  hip  has  been  done 
by  'blocking'  the  nerves,  though  I  believe  that  this  is  feasible  when 
it  is  possible  to  cut  the  soft  parts  at  a  lower  level,  as  in  the  Furneaux- 
Jordan  amputation.  In  such  a  case  the  preliminary  anesthesia  of  the 
anterior  crural  and  external  cutaneous  at  the  groin,  and  the  sciatic, 
just  below  the  gluteus  maximus  muscle,  will  suffice,  if  care  is  taken 
not  to  cut  the  obturator,  when  this  is  reached  in  making  the  deeper 
inner  section  of  the  thigh,  until  this  nerve  has  been  recognized  and 
infiltrated.  In  amputation  at  a  higher  level  (Wyeth's  operation) 
the  anesthesia  could  only  be  accomplished  by  a  preliminary  circular 
infiltration,  including  the  individual  nerve-trunks,  which  would  have 
to  be  anesthetized  as  they  were  met.  Such  a  procedure  would  tax  the 
self-control  of  the  patient  to  the  utmost,  and  would  be  so  tedious  that 
it  could  scarcely  be  recommended  except  in  very  thin  and  wasted 
subjects"  (Matas). 

In  amputations  at  the  lower  third  of  the  thigh,  as  well  as  at  the 
middle,  disarticulations  at  the  knee  or  amputations  at  the  knee,  as 
in  the  Gritti-Stokes  operation,  the  difficulties  presented  by  the  ob- 
turator nerve  are  more  easily  met.  The  anterior  crural,  external 
cutaneous,  great  sciatic,  and  lesser  sciatic  should  all  be  injected  intra- 
neurally  at  the  root  of  the  limb  with  0.5  of  i  per  cent,  novocain  solu- 
tion, with  a  few  drops  of  adrenalin  solution  (1:1000)  to  the  ounce. 
It  is  very  necessary  not  to  overlook  the  lesser  sciatic,  which  lies  just 
to  the  inner  side  of  the  great  sciatic,  where  this  nerve  enters  the  limb, 
as  its  branches  are  distributed  to  the  skin  as  low  down  as  the  popliteal 
space  and  back  part  of  the  leg;  it  is  probable  that  some  failures  re- 
ported by  this  method  have  been  due  to  this  neglect  as  well  as  to 
other  details.  It  is  more  convenient,  when  operating  by  the  neuro- 


268  LOCAL   ANESTHESIA 

regional  method,  to  use  a  posterior  rachet  incision.  After  the  poste- 
rior incision  has  been  made,  and  the  deep  muscles  slightly  separated 
with  the  finger  to  expose  the  vessels,  a  long  needle  is  used  to  infiltrate 
the  region  around  the  vessels  (the  path  of  the  obturator  nerve)  with 
solution  No.  i  or  less  freely  with  0.5  per  cent,  novocain.  A  few  min- 
utes following  this  last  injection  all  parts  involved  in  the  field  of 
operation  should  be  as  anesthetic  as  under  general  narcosis  and  the 
steps  of  the  operation  proceeded  with  in  the  usual  way.  It  would 
seem  unnecessary  to  state  that  all  these  operations  should  be  per- 
formed with  the  use  of  a  constrictor  applied  to  the  upper  part  of  the 
thigh  after  the  injection  of  the  crural,  external  cutaneous,  and  sciatic 
nerves. 

To  expose  the  sciatic  nerve  for  intraneural  injection  the  following 
method  will  be  found  to  be  quick,  simple  and  accurate.  •  In  the  upper 
part  of  the  thigh  just  below  the  gluteal  fold  the  nerve  lies  on  an 
antero-posterior  plane  that  passes  midway  between  the  great  trochan- 
ter  and  tuberosity  of  the  ischium,  laterally  it  lies  on  a  plane  that 
passes  through  the  posterior  surface  of  the  femur  lying  i  inch  internal 
to  that  bone.  To  expose  it  proceed  as  follows: 

Make  an  intradermal  wheal  on  the  above  midline  just  below  the 
gluteal  fold;  take  a  long  fine  needle  and  large  syringe  and  enter 
through  this  wheal  directing  the  needle  subcutaneously  down  the  leg 
for  about  4  inches  injecting  as  it  is  advanced,  partly  withdraw  the 
needle  and  direct  it  on  a  slightly  deeper  plane  for  the  same  distance. 
Now  direct  it  straight  down  through  the  wheal  for  a  distance  of  about 
3  inches  injecting  freely  as  it  is  advanced;  repeat  this  deep  injection 
in  a  similar  manner  at  one  or  two  more  points  along  the  infiltrated 
line. 

A  few  minutes  delay  will  establish  complete  anesthesia,  when  the 
incision  can  be  made  and  should  be  carried  down  through  the  deep 
fascia,  no  further  incisions  are  needed,  as  the  hamstring  muscles  are 
easily  separated  by  the  finger  which  feels  its  way  down  to  the  level 
of  the  femur  where  the  nerve,  a  trunk  as  large  as  the  little  finger,  will 
be  found  lying  i  inch  on  its  inner  side. 

The  small  sciatic  nerve  also  lies  on  the  antero-posterior  line  just 
superficial  to  the  deep  fascia  and  is  consequently  blocked  by  the  in- 
filtration. 

The  incisions  made  to  expose  these  nerves  should  not  be  perma- 
nently closed  until  the  operation  is  completed,  but  only  loosely  ap- 
proximated with  superficial  stitches,  for  if  anesthesia  is  not  complete 
it  may  be  necessary  to  reopen  the  wounds  for  further  infiltration  of 


THE    UPPER  AND   LOWER   EXTREMITIES 


269 


the  nerves;  this,  however,  will  not  be  at  all  likely  if  the  nerve  has  been 
properly  infiltrated,  producing  a  fusiform  enlargement  at  the  point 
of  injection,  in  the  case  of  a  very  large  nerve  like  the  great  sciatic 
entering  the  needle  at  two  or  more  points  in  the  nerve.  As  men- 
tioned elsewhere,  this  should  be  done  with  a  very  fine  needle  entered 
in  the  long  axis  of  the  nerve-fibers;  care  should  also  be  observed  not 
to  make  traction  on  the  nerve,  which  will  cause  pain,  but  to  make 
the  injection  when  the  nerve  is  slack.  Some  operators  in  discussing 
these  operations  have  preferred,  after  injecting  the  anterior  crural 
and  external  cutaneous  nerves  at  Poupart's  ligament,  to  infiltrate 


Fig.  51. — Method  of  securing  anesthesia  of  femur  for  supracondyloid  osteotomy.  (Braun.) 

the  superficial  tissues  on  the  back  of  the  thigh,  making  the  handle  of 
the  racket  incision  first,  and  exposing  the  sciatic  nerve  or  its  branches 
at  the  upper  part  of  this  incision  and  injecting  them  high  up  here, 
then  infiltrating  the  recognized  course  of  the  obturator  nerve.  The 
objection  we  have  to  offer  to  this  procedure  is  that  the  small  sciatic  is 
not  injected,  and  its  territory,  together  with  that  of  any  of  the  bran- 
ches of  the  great  sciatic  given  off  above  the  point  of  its  injection,  will 
have  to  be  infiltrated.  In  the  operations  about  the  knee-joint — 
disarticulations  and  Gritti-Stokes  amputation — these  objections  are 
not  of  as  much  consequence,  as  the  area  here  to  be  infiltrated  is  nec- 
essarily much  smaller. 


270  LOCAL   ANESTHESIA 

For  operations  upon  the  femur,  as  in  the  removal  of  osteomas, 
sequestrotomy,  etc.,  the  method  of  injecting  around  the  bone  is  shown 
graphically  in  Fig.  51 .  If  the  operation  is  to  be  performed  exclusively 
by  infiltration,  the  soft  parts  must  be  infiltrated  from  the  skin  to  the 
periosteum  along  the  proposed  line  of  incision;  or  superficial  regional 
methods  may  be  employed,  in  addition  to  the  periosteal  injections, 
by  blocking  the  external  cutaneous  or  anterior  crural  nerves  just  be- 
low Poupart's  ligament,  and  this  would  seem  the  preferable  plan 
except  in  emaciated  subjects. 

THE  KNEE-JOINT 

As  this  joint  receives,  either  in  its  cutaneous  covering  or  deeper 
parts,  branches  from  practically  all  the  nerves  in  the  lower  part  of 
the  thigh,  what  has  been  said  regarding  the  neuroregional  methods  of 
that  part  are  equally  applicable  here. 

It  will  be  seen  that  the  deeply  situated  and  difficultly  accessible 
obturator  nerve  may  offer  serious  obstacles  to  a  thorough  and  satis- 
factory anesthesia  of  this  part;  it  is  here,  then,  that  Bier's  venous 
anesthesia  or  spinal  puncture  may  be  advantageously  used;  however, 
in  the  hands  of  the  skilful  operator,  this  disadvantage  may  be  over- 
come, and  almost  any  operation  on  the  joint  performed  by  purely 
regional  methods. 

First  block  the  anterior  crural,  external  cutaneous,  and  sciatic 
nerves  at  the  root  of  the  limb ;  this  will  leave  only  the  territory  sup- 
plied by  the  obturator  unanesthetized,  which  is  represented  by  a 
small  area  on  the  inner  side  of  the  knee  and  a  part  of  the  joint.  With 
all  the  other  parts  anesthetized,  the  operative  incision  could  be  made 
in  such  a  way  as  to  expose  or  easily  approach  the  path  of  the  obtura- 
tor nerve  on  the  inner  side  and  just  above  the  knee,  and  sufficiently 
deep  to  feel  freely  the  femoral  vessels;  rather  free  infiltration  between 
and  around  the  vessels  and  on  their  inner  side  should  reach  all 
branches  of  the  nerve  and  leave  the  parts  below  completely  anes- 
thetic. Such  a  thorough  procedure  as  the  above  will,  however, 
only  be  necessary  in  extensive  resections  of  the  joint,  many  lesser 
procedures  involving  only  the  anterior  parts  of  the  joint  (the  parts 
most  frequently  the  site  of  surgical  intervention)  can  be  easily 
performed  through  infiltration,  or  by  blocking  the  anterior  crural 
and  external  cutaneous  nerves  at  Poupart's  ligament.  The  latter 
procedure  will  suffice  for  the  operative  treatment  of  fracture  of  the 
patella,  drainage  in  infected  arthritis,  the  removal  of  foreign  bodies, 
lipomatosis,  and  other  similar  conditions. 


THE    UPPER    AND    LOWER    EXTREMITIES 


271 


In  operating  upon  fracture  of  the  patella  by  infiltration,  the  joint 
cavity  should  be  filled  with  i  or  2  ounces  of  solution  No.  2,  with  5 
drops  of  adrenalin  (i  :  1000),  and  allowed  to  remain  for  from  five  to  ten 
minutes  before  the  joint  is  opened;  this  will  anesthetize  the  synovial 
surfaces  and  permit  the  painless  removal  of  clots  or  a  thorough  wash- 
ing out  of  the  joint  if  infected.  Even  strong  solutions,  up  to  2  per 
cent,  novocain,  could  be  used  if  necessary,  as  most  of  it  escapes  after 
the  joint  is  opened.  It  is,  of  course,  advisable  to  use  a  constrictor 
above  the  knee  in  extensive  operations  here  under  infiltration  and 
after  making  a  strong  intra-articular  injection.  The  method  of 
infiltrating  around  the  patella  region  is  seen  in  Fig.  52,  and  is  best 
done  as  follows:  Make  an  intradermal  wheal  about  2  inches  above 
the  patella,  enter  a  long  fine  needle  here  and  advance  it  subcuta- 


Fig.  52. — Peri-articular  infiltration  for  operation  in  patella  region.     (Braun.) 

neously  along  the  line  as  shown  in  Fig.  52,  injecting  freely  as  it  is 
advanced,  repeat  the  same  in  the  opposite  direction,  then  again  on  each 
side  on  a  deeper  plane  close  down  around  the  capsule  of  the  joint.  The 
needle  is  now  entered  laterally  where  the  last  injections  stopped  and 
subcutaneous  and  deep  injections  made  as  above  on  the  lateral  as- 
pects of  the  joint  curving  forward  so  as  to  partially  surround  the 
joint.  This  embraces  the  patella  in  a  horseshoe- like  area  of  infiltra- 
tion reaching  from  the  skin  to  the  capsule  of  the  joint.  After  a  delay 
of  a  few  minutes  it  should  sufficiently  diffuse  to  block  all  nerves  enter- 
ing the  field  from  above  and  on  the  sides.  As  no  nerves  enter  from 
below  it  is  unnecessary  to  complete  the  circle  by  the  injection  over 
the  ligamentum  patella  as  shown"  in  the  figure. 

Intra-articular  injections  may  be  made  use  of  in  breaking  up 


272  LOCAL   ANESTHESIA 

adhesions  within  the  joint  when  not  too  firm;  it  should  be  withdrawn 
after  five  or  ten  minutes  and  the  necessary  manipulations  resorted 
to;  or,  after  withdrawing  the  anesthetic  solution,  it  can  be  replaced 
with  the  2  per  cent,  formalin-glycerin  solution  of  Murphy,  which,  by 
its  hydroscopic  action,  moderately  distends  the  joint  cavity  and  thus 
prevents  further  immediate  contact  of  the  joint  surfaces,  particularly 
when  combined  with  extension. 

THE  LEG 

All  operations  below  the  knee,  involving  the  leg,  ankle,  and  foot, 
no  matter  what  their  extent,  can  be  painlessly  performed  by  a  single 
method.  When  near  the  knee,  by  injecting  the  external  cutaneous, 
anterior  crural,  and  sciatic  nerves  as  in  the  higher  operations;  if  some 
distance  below  the  knee  (middle  third  of  the  leg  and  below),  it  will  be 
sufficient  to  inject  the  sciatics  at  the  root  of  the  thigh  and  the  long 
saphenous  by  a  pareneural  injection,  made  transversely  over  the 
inner  surface  of  the  knee  between  the  tendons  of  the  sartorius  and 
gracilis  muscles,  where  this  nerve  becomes  superficial. 

It  would  seem  superfluous  to  detail  or  describe  the  many  opera- 
tions possible,  for  where  a  part  is  thoroughly  anesthetic  all  operations 
are  possible. 

The  following  is  taken  from  Prof.  Matas'  report  on  "Local  and 
Regional  Anesthesia,"  etc.,  1900,  and  cites  one  of  the  many  clinical 
cases  which  might  be  mentioned  to  illustrate  these  procedures: 

"Without  any  previous  knowledge  of  Crile's  work,  and  encour- 
aged by  previous  successes  with  the  same  methods,  as  applied  to  the 
upper  extremity,  I  performed  a  Pirogoff  operation  for  frost-bite  by 
this  method  in  March,  1899.  From  March,  1899,  to  present  date  I 
have  availed  myself  of  this  mode  of  anesthesia  many  times,  my 
colleagues  operating  on  other  cases  in  their  practice  at  the  Charity 
Hospital  and  elsewhere.  In  my  cases  there  were  reasons  which  made 
the  administration  of  a  general  anesthetic  undesirable. 

"In  one  of  these,  operated  on  before  the  medical  class  of  Tulane 
University,  the  inestimable  advantage  of  possessing  a  reliable  safe 
method  of  analgesia  as  an  alternative  to  general  narcosis  was  made 
particularly  apparent.  This  case  not  only  illustrates  the  circum- 
stances in  which  this  method  is  especially  applicable,  but  it  will 
serve  to  describe  the  technic  of  the  method  as  well. 

"F.  S.  W.,  aged  thirty-two,  was  admitted  to  the  hospital  December  18,  1899,  for  the 
treatment  of  a  diffuse  tubercular  arthritis  of  the  right  tarsus.  The  patient  was  suffering 
with  advanced  pulmonary  tuberculosis  (cavity  in  lung),  but  his  sufferings  were  so  great 


THE   UPPER   AND   LOWER   EXTREMITIES  273 

that  an  operation  was  decided  upon.  In  view  of  his  weakened  condition,  special  precau- 
tions were  taken  to  guard  against  the  accidents  of  general  anesthesia.  In  addition  to 
the  preparatory  administration  of  strychnin,  digitalis,  and  nitroglycerin  by  hypodermic, 
the  nares  were  sprayed  with  a  2  per  cent,  cocain  solution  to  diminish  the  nasolaryngeal 
reflexes  (Franck-Rosenberg).  Chloroform  was  then  administered  over  an  Esmarch 
mask  by  the  'guttatim'  method.  Notwithstanding  all  the  care  taken,  the  patient 
rapidly  entered  into  a  most  violent  stage  of  excitement  and  became  rigid  and  cyanosed; 
respiration  was  arrested,  the  pulse  became  irregular  and  imperceptible,  and  when  the 
tetanic  rigidity  ceased  the  patient  sank  as  if  completely  collapsed,  and  it  was  only  by  the 
immediate  application  of  artificial  respiration  and  other  measures  that  he  finally  came 
back  to  consciousness  again. 

"  As  the  operation  was  imperative  and  all  general  anesthetics  were  not  to  be  thought 
of  (ether  being  contra-indicated  by  the  phthisis),  I  decided  to  try  the  intraneural 
method  of  regional  anesthesia,  which  should  have  been  the  method  of  election  at  the 
start.  Accordingly,  after  careful  preparation  of  the  parts,  the  skin  and  underlying 
tissues  of  the  upper  popliteal  space  were  infiltrated  with  a  Schleich  No.  i  cocain  solution, 
and  an  incision  4  inches  long  was  made  so  as  to  bring  the  sciatic  nerve  into  view.  This 
done,  an  injection  of  25  minims  of  the  same  No.  i  (J^  of  i  per  cent.)  solution  was  injected 
into  the  trunk  of  the  nerve.  A  constrictor  was  applied — after  exsanguinating  the  limb 
by  gravity — care  being  taken  to  pad  the  limb  well  so  as  to  minimize  the  discomfort  it 
might  produce.  Eighteen  minutes  after  the  injection  of  the  cocain  some  sensibility 
still  existed  in  the  foot;  fearing  that  the  solution  would  be  insufficient,  20  minims  of  a  i 
per  cent,  cocain  were  then  injected  into  the  exposed  nerve.  In  three  minutes  the  anes- 
thesia of  the  entire  region  below  the  sciatic  infiltration  was  complete  and  the  operation 
was  begun  twenty-five  minutes  after  the  first  injection  into  the  nerve  had  been  given. 
The  tarsus  was  then  explored  by  making  a  free  externolateral  incision,  and  all  the  bones, 
including  the  tarsometatarsal  articulation,  were  found  to  be  involved  in  a  diffuse 
tuberculosis.  The  astragalus  alone  was  saved.  The  chisel,  gouge,  and  bone  curet  were 
used  freely  with  the  hope  that  a  simple  excision  might  suffice,  but  the  lesions  of  the  skele- 
ton and  soft  parts,  including  the  tendon-sheaths,  were  so  extensive  that  an  atypical 
subastragaloid  amputation  on  the  Roux-Lignerolles  plan  was  decided  upon.  The 
patient,  who  had  been  perfectly  quiet  and  passive,  was  now  asked  his  consent  to  the 
amputation,  which  at  first  he  refused,  but,  after  showing  him  the  extent  of  the  lesions 
and  explaining  to  him  the  advantages  of  a  radical  extirpation  in  a  man  in  his  condition, 
he  consented,  and  the  amputation  was  performed. 

"  The  patient  gave  us  very  material  assistance  in  this  operation,  not  only  by  holding 
his  foot  and  leg  in  the  most  favorable  attitudes  for  our  work,  but  by  turning  his  body 
around  without  assistance  when,  at  the  termination  of  the  operation  on  the  foot,  we 
closed  permanently  the  sciatic  incision.  The  contrast  between  the  alarming  condition 
induced  by  the  general  anesthetic  (chloroform)  and  the  passive  and  calm  attitude  of  the 
patient  throughout  the  operation  was  most  impressive.  In  this  case  it  should  be  men- 
tioned the  saphenous  nerve  was  not  injected,  as  in  the  other  similar  cases;  but,  instead 
of  this,  the  short  incision  through  the  skin  connecting  the  inner  border  of  the  foot  with 
its  outer  edge,  which  is  supplied  by  this  nerve,  was  bridged  over  by  a  line  of  infiltration 
edema.  The  operations  successfully  performed  by  this  method  in  my  practice  have 
been  (i)  Pirogoff's  amputation  for  frost-bite;  (2)  Syrne's  operation;  (3)  two  atypical 
resections  of  the  tibio-astragaloid  joint,  in  which  the  astragalus  and  calcaneum  were 
excised  together  with  the  tibiofibular  surfaces  and  their  malleoli,  for  tuberculosis;  (4) 
Guyon's  supramalleolar  amputation  of  the  leg  for  trauma;  and  (5)  an  extensive  search  in 
the  thigh  for  a  lost  bullet  embedded  in  the  neighborhood  of  Hunter's  canal.  In  the  last 
case  the  anterior  crural  nerve  and  external  cutaneous  were  cocainized  under  Poupart's 
ligament.  In  this  case  we  were  misled  in  the  situation  of  the  bullet  as  indicated  by 
radiograph,  and  failed  to  find  the  bullet  even  after  a  most  extensive  dissection  in  the 
18 


274 


LOCAL   ANESTHESIA 


lateral  and  posterior  femoral  aspects  of  the  thigh  had  been  made.  The  anesthesia  in 
this  case  was  complete  from  the  middle  of  the  thigh  to  the  toes,  but  there  was  marked 
sensation  in  the  upper  femoral  regions  in  consequence  of  the  preservation  of  the  lesser 
sciatic  filaments  which  overlapped  beyond  the  points  of  the  greater  sciatic  infiltration 
which  had  been  effected  just  below  the  crossing  of  the  lower  gluteal  fibers.  The  small 
area  of  persistent  dermal  sensibility  could  have  been  easily  controlled  by  a  short  trans- 
verse line  of  purely  dermal  infiltration,  the  deeper  parts  being  completely  insensitive." 

The  Toes,  Metatarsals,  and  Sole  of  the  Foot. — What  has  been 
said  regarding  the  fingers  and  metacarpals  may  be  largely  repeated 
for  the  foot.  With  certain  modifications,  any  of  the  smaller  toes  may 
be  easily  anesthetized  by  edemetization  carried  around  its  base. 
The  big  toe  is,  however,  more  effectually  treated  by  paraneural  in- 
jections made  around  the  base,  or,  as  in  Fig.  53 ,  where,  it  is  necessary 
to  remove  the  entire  toe.. 


Fig.  S3- — Points  of  injections  and  lines  of  infiltration  for  bunion  operations  or  resection 
of  great  toe.     (From  Braun.) 

Bunions. — This  common  annoyance  and  source  of  discomfort  is 
effectively  operated  in  the  following  manner.  Make  an  intradermal 
wheal  just  back  of  the  head  of  the  metatarsal  bone  on  the  inner  side 
of  the  foot,  enter  the  long  fine  needle  here  and  direct  it  subcutaneously 
over  the  dorsum  of  the  foot  obliquely  toward  the  interval  between 
the  first  and  second  toes  injecting  freely  as  the  needle  is  being 
advanced.  Partially  withdraw  the  needle  and  direct  it  subcuta- 
neously in  a  similar  direction  on  the  plantor  surface,  again  partially 
withdraw  it  to  near  the  starting  point  and  again  direct  it  toward  the 
interval  between  the  first  and  second  toes  this  time  passing  it  close  in 
contact  with  the  bone,  between  the  bone  and  the  muscles,  on  the  under 
surface  always  injecting  freely  while  it  is  being  advanced.  After  a 
few  minutes  delay  anesthesia  will  be  complete  for  both  bone  and  soft 


THE   UPPER   AND    LOWER   EXTREMITIES  275 

parts;  the  bone  can  be  resected  and  the  operation  performed  by  any 
technic  preferred.  I  have  used  this  method  a  large  number  of  times, 
it  is  quick,  simple  and  effective  and  has  always  been  followed  by 
excellent  results.  In  operating  for  ingrowing  toe-nails,  Dr.  Braun 
speaks  highly  of  the  use  of  ethylchlorid  spray,  used  about  the  base 
of  the  toe,  claiming  it  is  to  be  quite  sufficient  to  remove  the  matrix  as 
well  as  the  nail.  We  have  never  used  this  method,  always  preferring 
to  use  infiltration  or  paraneural  injections  at  the  base  with  solution 
No.  i,  to  which  is  added  5  drops  of  1:1000  adrenalin  to  the  ounce. 
This  method  has  the  advantage  of  producing  quite  a  lasting  analgesia, 
and  by  the  time  sensation  does  return  very  little  pain  is  experienced ; 
should  the  operation  be  performed  in  the  office  and  the  patient 
allowed  to  go  home  afterward,  he  is  likely  to  reach  his  destination 
before  any  discomfort  is  felt,  although  few  rarely  complain  of  any 
but  slight  soreness  following.  Figure  56  shows  method  of  anesthetiz- 
ing the  lesser  toes,  and  should  be  done  in  the  same  manner  described 
for  similar  operations  on  the  hand. 

In  operations  upon  the  sole  of  the  feet  for  removal  of  splinters  and 
other  foreign  bodies  it  is  often  quite  a  difficult  matter  to  satisfactorily 
infiltrate  the  pulp  of  the  foot;  this  tissue  is  so  dense  and  unyielding 
that  even  with  solutions  of  considerable  strength  much  difficulty  is 
experienced.  Rather  than  continue  at  efforts  of  infiltration  after 
this  has  been  found  difficult,  it  would  be  simpler  and  preferable  to  at 
once  make  a  paraneural  injection  around  the  posterior  tibial  nerve,  as 
described  in  the  following  experiments,  thus  securing  at  once  anesthe- 
sia of  the  entire  foot;  additional  injections  being  made  over  the 
inner  or  outer  ankles  to  reach  the  branches  of  the  long  saphenous  or 
peroneal  nerves  should  this  be  necessary.  A  review  of  the  follow- 
ing quotations  from  Braun  ("De  Lokal  Anesthesie"),  will  suggest 
many  useful  applications  in  practical  surgery  when  limited  in  extent 
or  confined  to  the  superficial  parts,  but  any  extensive  operations 
involving  resections  of  the  foot  had  better  be  performed  by  the 
intraneural  methods  of  blocking  the  nerve  higher  up,  as  already 
described. 

Figure  54,  from  Braun  ("Die  Lokal  Anesthesie"),  shows  a  cross- 
section  through  the  ankle-joint,  at  the  level  of  the  most  prominent 
portion  of  the  internal  malleolus;  the  posterior  tibial  nerve  is  best 
reached  as  indicated  by  the  arrow,  the  artery  lying  internal  to  the 
nerve.  Braun  gives  the  following  directions  for  reaching  it  at  this 
point:  "The  needle  is  inserted  about  i  cm.  from  the  inner  side  of 
tendo  achilles,  and  directed  from  behind  forward  until  the  posterior 


276 


LOCAL   ANESTHESIA 


Extensor  hall. 

Superf.  peroneal  nerve  —"/* 
Deep  peroneal  nerve 


Extensor  dig. ' 


..'Tibialis  ant. 


,.  Tibialis  post. 
.^  Flexor  dig. 


Peroneal  mus 

Flexor  hall.    *' 


Ext.  saphenous  nerve '' 

- — Method  of  reaching  posterior  tibial  nerve  at  ankle-joint  for  paraneural 
injection.     (From  Braun.) 


i 


L    • 

Fig.  55. — Lines  of  subcutaneous  infiltration  and  resulting  areas  of  anesthesia  in  foot. 

(From  Braun.) 


THE    UPPER   AND    LOWER   EXTREMITIES 


277 


surface  of  the  tibia  is  reached;  the  needle  is  then  slightly  withdrawn 
and  the  solution  injected.  He  states  that  the  injury  of  the  vessel 
which  lies  on  the  inner  side  of  the  nerve  is  hardly  to  be  feared,  but  it 
should  first  be  made  sure  that  the  point  of  the  needle  is  not  in  the 
vessel,  by  resorting  to  a  little  aspiration  before  the  injection  is  made 
by  slightly  withdrawing  the  plunger.  Should  it  be  found  that  the 
vessel  has  been  punctured,  no  unpleasant  consequences  are  likely 
to  result  if  the  needle  has  been  fine." 

The  following  experiment  indicates  the  results  of  an  injection 
made   in    this   manner: 


Fig.  56. — Disarticulation  of  third  toe.     (From  Braun.) 

"Experiment  i  (Dr.  B.).  One-half  cubic  centimeter  of  a  i  percent,  solution  with  i 
drop  of  adrenalin  (i:  1000)  was  injected  in  the  above-described  manner,  and  almost  im- 
mediately anesthesia  appeared  as  indicated  in  Fig.  55,  No.  I,  and  lasted  for  three  hours. 
The  affected  area  on  the  extensor  surface  of  the  foot  and  toe  is  indicated  by  the  shaded 
surface." 

This  procedure  was  once  employed  for  opening  an  abscess  and 
removing  a  foreign  body  from  the  sole  of  the  foot.  The  anesthesia 
extends  to  the  metatarsals  and  tarsus: 

"  Experiment  2.  Two  cubic  centimeters  of  o .  5  per  cent,  cocain  solution  with  4  drops 
adrenalin  solution,  injected  subcutaneously  over  the  inner  ankle,  beginning  behind  the 
tendo  Achillis  and  extending  around  to  the  middle  line  of  the  joint  in  front.  This  will 
meet  the  terminal  branches  of  the  internal  saphenous  nerve;  the  extent  of  the  resulting 
anesthesia  is  shown  in  Fig.  55,  No.  II." 


278  LOCAL  ANESTHESIA 

The  injection  in  Experiment  2  reaches  the  terminal  branches 
of  the  internal  saphenous  nerve,  and  may  often  be  combined  with  the 
injection  of  the  posterior  tibial,  as  in  Experiment  i,  for  anesthesia  of 
the  inner  side  and  sole  of  the  foot. 

In  commenting  upon  these  experiments,  Braun  states  that  a 
subcutaneous  injection,  made  across  the  extensor  surface  of  the 
ankle-joint,  reaches  only  a  few  of  the  fibers  of  the  internal  saphenous 
and  produces  only  a  limited  area  of  anesthesia  on  the  back  of  the 
foot,  the  same  as  in  a  corresponding  injection  made  on  the  back  of  the 
hand,  while  a  much  more  extensive  area  is  affected  if  the  injection  is 
made  slightly  higher,  as  in  Experiment  3,  where  the  superficial 
branches  of  the  peroneal  nerves  are  reached. 

"Experiment  3.     Three  cubic  centimeters  of  0.5  per  cent,  cocain  solution  with  the 
addition  of  10  drops  adrenalin  solution  (1:1000)  was  injected  a  hand's  breadth  above 


Fig.  57. — Area  of  anesthesia  for  tenotomy  of  tendo  Achillis.     (Braun.) 

the  outer  ankle,  across  the  axis  of  the  limb,  from  the  tendo  Achillis  behind  to  the  edge  of 
the  tibia  in  front.  After  six  minutes  the  skin,  as  indicated  in  Fig.  55,  No.  Ill,  had  be- 
come anesthetic  and  remained  so  for  three  to  four  hours." 

In  discussing  this  experiment,  Braun  states  that  this  injection 
reaches  all  of  the  superficial  fibers  of  the  peroneal  nerve,  the  anes- 
thetic field  extending  from  the  territory  of  distribution  of  the  internal 
saphenous  at  the  inner  ankle  and  inner  side  of  the  foot  across  the 
dorsum  to  the  outer  side  of  the  foot.  The  results  obtained  in  Ex- 
periment 4  may  also  at  times  be  applied  practically. 

"Experiment  4.  Three  fmgers'-breadth  above  the  internal  ankle  the  needle  was  en- 
tered laterally,  between  the  tendons  of  the  tibialis  anticus  and  extensor  hallucis  longus, 
vertical  to  the  cutaneous  surface  till  the  bone  was  reached;  the  needle  was  now  turned 
laterally  under  the  tendon  of  the  extensor  hallucis  and  an  injection  of  i  c.c.  of  0.5  per 
cent,  cocain  with  3  drops  adrenalin  solution  (i  :  1000)  was  injected;  ten  minutes  later 
anesthesia  was  established  in  the  terminal  branches  of  the  peroneus  profundus,  as  indi- 
cated in  Fig.  55,  No.  IV." 

The  method  of  infiltration  for  tenotomy  of  the  tendo  Achillis  is 
shown  in  Fig.  57,  the  infiltration  carried  well  down  around  the  tendon. 


CHAPTER  XV 
NECK 

"!N  the  surgery  of  this  region  local  anesthesia  has  made  large 
and  permanent  conquests.  The  neck  is  most  favorable  for  the  dis- 
play of  the  infiltration  method,  the  paraneural  and  intraneural  meth- 
ods of  regional  anesthesia  having  found  comparatively  few  typical 
applications.  In  the  neck  the  lesion  of  the  skin  and  its  appendages 
and  those  of  the  supra-aponeurotic  planes  are  everywhere  submissive 
to  cocain  or  its  allies.  Local  infiltration  is  most  valuable  in  dealing 
with  inflammatory  lesions — abscesses,  boils,  inflamed  sebaceous  cysts, 
and  carbuncles  of  moderate  size.  In  opening  deep  cervical  abscesses 
connected  with  submaxillary  and  pharyngotonsillar  infections,  in 
which  the  suppurative  focus  must  be  reached  by  careful  dissection 
(the  Hilton-Rose  method),  it  is  invaluable. 

"In  the  major  surgery  of  the  neck,  local  infiltration  finds  its  most 
brilliant  applications  in  the  anterior  cervical  and  subclavian  regions, 
and  in  the  operations  on  the  vessels  in  the  carotid  triangles. 

"Apart  from  the  avoidance  of  postoperative  constitutional  dis- 
turbances, the  immediate  advantages  local  of  anesthesia  are  that  it 
permits  the  dissection  of  the  parts  with  the  precision,  neatness,  and 
deliberation  that  are  required  in  all  the  deep  vascular  regions;  that 
the  great  turgidity  of  the  veins  and  general  increase  in  vascularity 
incident  to  the  use  of  inhalation  anesthetics  is  avoided;  and  that  the 
surgeon  is  materially  assisted  in  his  work  by  the  different  attitudes 
that  the  patient  can  assume  to  favor  the  better  exposure  of  the  parts. 

"In  the  postcervical  triangle  the  conditions  for  local  anesthesia 
are  less  favorable,  except  in  the  supraclavicular  space,  in  which  the 
subclavian  artery  and  brachial  plexus  are  readily  exposed  for  opera- 
tive purposes"  (Matas). 

Nerves  of  the  Neck. — In  the  neck  the  only  opportunity  for  the 
application  of  regional  methods  of  anesthesia,  aside  from  paraverte- 
bral  methods,  is  the  superficial  branches  of  the  cervical  plexus  as  they 
emerge  around  the  posterior  border  of  the  sternomastoid  about  the 
middle  of  the  neck  (Fig.  58).  Here  the  occipitalis minor,  auricularis 
magnus,  superficialis  colli,  and  the  descending  or  supraclavicular 
branches  are  all  fairly  accessible,  and  in  their  emergence  from  the 

279 


280 


LOCAL   ANESTHESIA 


deeper  parts  are  all  met  within  a  comparatively  limited  area.     To 
reach  and  block  these  nerves  in  this  position  it  is,  however,  not 

;\ 


posterior  facial  vein. 


Ptatysma  x 

cervical  branch  o, 
facial  nerve 


posterior 
/auricular  vein 

Sternocleido- 
/'  mastnidcus 


cervical  nerve 

external  jugular  vein^^ 
cutaneous  eervical  nerve    JPv 


-great  occipital  nmr 

occipital  vein 
occipital  artery 


•sailor  brs.  of  cervical  plexus 
Omohyoideus  (inferior  telly) 

^    posterior  supraclavicular 
nerves 


anterior  supraclavicular  nerves 


middle  supra- 
clavicular  nerves 


Fig.  58. — The  superficial  nerves  and  veins  of  the  left  side  of  the  neck  (second  layer 
of  neck).  The  platysma  has  been  divided,  the  upper  portion  reflected  toward  the  jaw, 
and  the  lower  portion  removed.  The  fascia  has  been  divided  along  the  facial  veins. 
X  =  Anastomosis  of  accessory  nerve  with  cervical  plexus,  -f-  =  Communication  of  ex- 
ternal jugular  vein  with  deep  veins.  The  upper  perforating  branches  of  the  internal 
mammary  vessels  (not  represented  in  the  illustration)  make  their  appearance  between 
the  origins  of  the  sternocleidomastoideus.  (Sobotta  and  McMurrich.) 

necessary  to  make  an  open  dissection,  though  this  can  be  done; 
applying  intraneural  or  perineural  injections  to  each  individual  nerve, 


NECK 


28l 


it  will,  however,  be  found  equally  satisfactory  and  much  simpler  to 
pass  a  long  needle  down  to  the  posterior  region  of  the  sternomastoid 
at  the  midpart  of  its  course  to  the  point  of  emergence  of  these  nerves, 
and  here  making  a  fairly  liberal  infiltration  of  from  3  to  4  drams  of 
i  per  cent,  novocain,  containing  a  few  drops  of  adrenalin,  distributing 
the  solution  up  and  down  this  area  for  about  2  %  inches,  thus  effectu- 
ally reaching  all  these  nerves.  The  result  of  such  an  injection  is 
seen  in  the  anesthetic  area,  as  indicated  in  Fig.  59  (ten  or  fifteen 
minutes'  delay  is  necessary  for  the  full  effect  to  be  shown).  The 
anesthesia  of  the  superficial  parts  is  complete  almost  to  the  mid- 
line  of  the  neck;  here  the  nerves  from  the  opposite  side  lap  over; 
it  will  consequently  be  necessary  to  make  the  injection  on  both 
sides  if  the  operation  is  to  be  near  the  midline. 


Fig.  59. — Line  of  deep  subcutaneous  infiltration  over  sternomastoid  and  resulting  area 
of  anesthesia.     (From  Braun.) 

The  depth  of  the  anesthesia  will  depend  upon  the  depth  of  the 
injection;  however,  in  making  the  injection  into  the  deep  parts, 
care  should  be  taken  not  to  pass  the  needle  too  far  forward  under 
the  sternomastoid,  for  fear  of  injuring  the  deep  vessels  in  this  posi- 
tion. 

Some  of  the  deep  branches  will  be  found,  upon  deep  dissections, 
to  have  escaped  the  effect  of  the  injection;  these  deep  branches  are 
for  the  anterior  parts,  communicating  branches  to  the  pneumogastric, 
hypoglossal,  and  sympathetic  nerves,  communicans  hypoglossi  and 
muscular  branches;  posteriorly,  these  are  communicating  branches 
to  the  spinal  accessory  and  a  deep  muscular  set. 

However,  for  extensive  dissections  of  this  region,  the  above- 
mentioned  method  will  be  found  extremely  helpful,  greatly  lessening 


282  LOCAL   ANESTHESIA 

the  amount  of  infiltration  which  will  be  needed,  and  this  only  in  the 
deeper  parts. 

Innervation  of  the  Larynx. — This  is  through  the  superior  and 
inferior  laryngeal  nerves.  The  superior  laryngeal  divides,  by  the 
side  of  the  pharynx,  into  internal  and  external  branches;  the  internal, 
the  principal  nerve  of  sesation,  passes  through  the  thyrohyoid  mem- 
brane, about  ^  inch  below  the  posterior  extremity  of  the  hyoid  bone, 
and,  after  coursing  a  short  distance  forward  between  the  membranes, 
enters  the  larynx;  this  nerve  supplies  sensation  to  all  parts  above  the 
vocal  cords  as  far  as  the  base  of  the  tongue. 


Fig.  60. — Method  of  making  paraneural  injection  for  superior  laryngeal  nerve. 

To  reach  this  nerve  for  regional  infiltration  have  the  patient  lie 
on  his  back,  with  a  small  pillow  under  the  back  of  his  neck;  have  an 
assistant,  by  pressure  on  the  opposite  side,  displace  the  hyoid  bone 
from  one  side,  rendering  it  more  prominent;  with  an  index-finger 
on  the  great  cornu,  the  needle  is  passed  down  in  this  direction  and  2 
or  3  c.c.  of  0.5  per  cent,  novocain  with  i  drop  of  adrenalin  (1:1000) 
is  injected  into  the  thyrohyoid  membrane,  a  little  below  and  in  front 
(about  %  inch)  of  the  great  cornu  (Fig.  60);  the  opposite  side  is 
treated  the  same  way;  the  anesthesia  appears  in  from  five  to  ten 
minutes,  and  frequently  lasts  one  hour  or  longer,  and  is  sufficient  for 
all  operations  above  the  vocal  cords.  The  external  laryngeal  passes 


NECK  283 

down  the  side  of  the  larynx  beneath  the  sternothyroid  and  is  distrib- 
uted to  the  crico thyroid  muscle;  it  also  contains  sensory  filaments. 
The  inferior  or  recurrent  iaiyngeal  passes  up  in  the  groove  between 
the  trachea  and  esophagus,  and  passes  under  the  lower  border  of  the 
inferior  constrictor;  entering  the  larynx  behind  the  articulation  of 
tributed  to  all  muscles  except  the  cricothyroid,  and  supplies  sensation 
to  all  parts  below  the  vocal  cords. 

Before  the  introduction  of  cocain  and  its  successful  application 
to  this  region  investigators  attempted  to  produce  anesthesia  of  the 
larynx  in  many  ways.  Eulenburg  injected  solutions  of  morphin  into 
the  thyrohyoid  membrane  at  the  point  of  entrance  of  the  internal 
laryngeal  nerve,  and  obtained  in  this  way  a  certain  amount  of  anes- 
thesia of  the  larynx.  Later  other  substances,  such  as  saponin,  were 
used  in  a  similar  way  by  Pelikan,  Kohler,  and  others.  Rossbach  has 
produced  an  anesthesia  of  the  larynx  by  freezing  the  tissues  over  the 
point  of  entrance  of  the  above  nerve  for  two  or  three  minutes  by  the 
use  of  ether  spray.  Since  the  advent  of  cocain  and  its  congeners, 
these  earlier  efforts,  while  in  the  right  direction,  are  only  of  interest 
historically. 

OPERATIONS  ON  THE  NECK 

Ligation  of  the  Common  Carotid  Artery. — This  is  easily  access- 
ible in  any  part  of  its  course.  Infiltration  with  a  few  drams  of  solu- 
tion No.  i,  used  first  in  the  skin  and  subcutaneous  tissue  and  success- 
ively in  the  deeper  layers  as  they  are  approached  (Fig.  61),  renders 
this  procedure  extremely  easy;  with  very  few  exceptions  this  vessel 
should  never  be  ligated  except  under  local  anesthesia,  and,  instead  of 
the  ordinary  ligature,  it  is  far  safer  to  use  aluminum  bands,  as  recom- 
mended by  Matas  and  Allen.  It  has  been  recognized  that  it  is  never 
safe,  even  in  young  subjects  (here  we  may  have  deficiencies  in  the 
circle  of  Willis) ,  to  cut  off  the  blood-supply  from  such  vessels  as  the 
common  or  internal  carotid  without  first  being  sure  of  the  com- 
petency of  the  collateral  circulation;  for  this  reason  ligation  or  oc- 
clusion should,  if  possible,  always  be  done  under  local  anesthesia,  so 
that  the  sensations  of  the  patient  may  at  once  be  determined,  which 
would  not  be  the  case  with  a  general  anesthetic,  and,  instead  of  using 
a  ligature  which  produces  permanent  damage  to  the  artery,  the 
aluminum  bands,  as  recommended  by  the  author,  should  be  substi- 
tuted, which  are  capable  of  removal  without  damage  to  the  vessel, 
if  necessary,  as  long  after  as  seventy-two  hours. 


284 


LOCAL   ANESTHESIA 


It  is  accordingly  always  our  practice  to  occlude  these  vessels  in 
the  above  manner  and  always  under  local  anesthesia.1 

The  internal  and  external  carotids,  except  in  very  stout  subjects 
and  in  case  of  abnormally  high  division,  are  easily  exposed  at  their 
origins  through  infiltration  with  local  anesthesia  and  need  no  special 
description  (Fig.  61). 

The  internal  jugular  vein,  except  at  the  base  of  the  skull,  is  easily 
accessible  throughout  its  entire  course,  and  may  require  ligation  or 
excision,  as  in  the  case  of  septic  thrombosis  from  middle-ear  disease. 
In  operating  under  conditions  of  this  kind,  where  it  is  often  uncertain 


Fig.  61. — i,  Area  of  anesthesia  for  exposing  external  carotid  artery;  2,  common  carotid. 

to  what  extent  the  vessel  will  have  to  be  exposed,  it  is  preferable  to 
block  the  cervical  plexus  as  already  described,  thus  securing  anes- 
thesia of  the  superficial  parts  throughout  the  entire  extent  of  the  vein; 
it  would  then  be  necessary  to  use  only  light  infiltration  anesthesia 
as  the  deeper  parts  are  approached. 

The  subclavian  artery  is  easily  exposed  by  infiltration  in  its 
second  and  third  portions,  but  has  been  ligated  without  much  diffi- 
culty, and  painlessly  by  Matas  in  the  first  portion. 

1  Occlusion  of  large  surgical  arteries  with  removable  metallic  bands  to  test  the  effi- 
ciency of  the  collateral  circulation  (Matas  and  Allen,  "Jour.  Amer.  Med.  Assoc.,"  Jan- 
uary 28,  1911). 


NECK  285 

Lymphatic  Glands. — Isolated  groups  of  diseased  glands,  when 
well  denned  and  circumscribed,  are  best  removed  by  the  Hacken- 
bruch  method  which  is  illustrated  in  Figs.  19-49  and  described  in 
connection  with  Scarpa's  triangle  and  the  inguinal  region  on  page  263. 
In  these  injections  care  should  be  exercised  not  to  make  the  injections 
within  the  substance  of  a  diseased  gland  which  might  cause  its 
rupture  with  the  liberation  of  the  infection. 

When  necessary  to  resort  to  a  complete  extirpation  of  all  the 
glands  of  the  neck,  as  may  occasionally  be  necessary  in  tubercular 
adenitis,  this  can  be  quite  satisfactorily  done  with  local  methods, 
where  there  is  not  much  infiltration  and  matting  of  the  tissues  and 
the  glands  have  not  broken  down  too  extensively.  For  these  exten- 
sive operations  we  should  avail  ourselves  of  regional  methods  as 
much  as  possible,  as  described  on  pages  281  and  289.  In  this  case 
after  making  the  paraneural  injections  with  stronger  solutions  the 
infiltrations  elsewhere  can  be  made  with  quite  weak  solutions,  and 
as  in  all  similar  extensive  dissections  it  is  preferable  to  complete 
the  entire  infiltration  of  the  field  as  much  as  possible  before  beginning 
the  operation.  The  location  and  extent  of  the  glands  will  govern  the 
areas  to  be  infiltrated:  in  addition  to  the  cervical  plexus  already 
mentioned  two  sources  of  nerve-supply  should  be  blocked;  first  in 
the  upper  part  of  the  neck  in  the  upper  portion  of  the  carotid  triangle 
an  extensive  nerve  plexus  is  formed  largely  from  fibers  of  the  pneumo- 
gastric,  hypoglossal  and  cervical  nerves  which  descends  around  the 
great  vessels.  On  the  outer  side  of  this  space  is  found  the  spinal 
accessory.  These  deep  nerves  are  best  reached  by  directing  a  long 
fine  needle  down  through  the  tissues  just  below  the  parotid  gland 
injecting  as  the  needle  is  advanced  to  just  beneath  the  deep  fascia 
where  from  %  to  i  ounce  of  solution  is  injected  at  two  or  more 
points.  In  advancing  a  needle  down  into  such  regions  where  the 
vessels  are  large  and  numerous  the  solution  should  be  continuously 
injected  as  the  needle  is  being  advanced,  and  if  any  doubt  is  enter- 
tained regarding  the  needle  having  entered  a  vessel  slight  aspiration 
on  the  piston  will  clear  any  doubt.  If  properly  made  and  in  suffi- 
cient quantity  these  injections  will  reach  all  necessary  nerves  in 
this  space  and  occasionally  may  reach  the  pneumogastric  and  sym- 
pathetic cord  in  effective  quantities-.  For  this  reason  these  injections, 
as  well  as  deep  ones  low  down  in  the  neck  where  they  may  reach  the 
phrenic  nerve,  should  not  be  done  on  both  sides  of  the  neck  at  the 
same  time.  Deep  injections  similar  to  the  above  may  be  necessary 
in  the  lower  part  of  the  neck  to  reach  fibers  from  the  brachial  plexus 


286  LOCAL   ANESTHESIA 

and  other  cervical  nerves  which  are  distributed  to  these  deeper  parts. 
This  last  injection  is  best  made  by  passing  the  needle  down  just  above 
the  clavicle  on  the  outer  edge  of  the  sternomastoid  muscle  to  just 
beneath  the  deep  fascia  and  again  slightly  higher  and  distributing 
about  ^  ounce  of  solution  at  these  points,  observing  the  same  pre- 
cautions for  making  these  injections  as  given  above.  With  these 
several  injections  properly  made  it  is  possible  to  control  practically 
the  entire  innervation  down  to  the  deep  muscles.  Occasionally 
small  sections  of  tissue  will  be  found  to  have  escaped  the  anesthesia 
and  will  have  to  be  separately  injected. 

Malignant  disease  unless  superficial  or  well  defined,  had  better 
be  operated  by  general  anesthesia  unless  contra-indicated;  when 
operating  by  local  methods,  as  already  advised,  care  must  be  taken 
not  to  infiltrate  diseased  tissues,  but  to  create  a  zone  of  anesthesia 
around  the  area  to  be  extirpated  by  the  Hackenbuch  plan;  non- 
malignant  growths  when  well  defined  are  easily  removed  (Fig.  19). 
Malignant  disease  of  the  submental  and  submaxillary  glands  associated 
with  lesions  of  the  lip  are  described  in  the  chapter  on  the  head  and 
face. 

The  following  case,  reported  by  Dr.  Matas  in  1900,  illustrates  the 
possibilities  here: 

"One  of  the  most  extensive  operations  performed  with  cocain  anesthesia  was  the  ex- 
tirpation of  a  large  retropharyngeal  fibroma  of  more  than  thirty  years'  duration  in  a  very 
aged  negro,  who  sought  relief  in  our  hospital  service  four  years  ago.  In  this  case  the 
removal  of  the  growth  became  imperative,  on  account  of  progressive  inanition  and  mar- 
asmus induced  by  the  outward  displacement  of  the  pharynx  and  esophagus.  The  larynx 
and  trachea  were  also  so  displaced  by  the  neoplasm  that  breathing  was  seriously  ob- 
structed. The  huge  mass  occupied  the  right  half  of  the  neck  and  bulged  under  and  to 
the  outer  side  of  the  sternomastoid,  which  was  spread  like  a  thin  sheet  in  front  and  to 
the  inner  side  of  it.  The  right  carotid  was  displaced  to  the  left  of  the  median  line  and 
could  be  felt  pulsating  under  the  skin.  The  skin  was  cocainized  in  a  line  extending 
from  the  mastoid  to  the  sternoclavicular  joint  in  the  long  axis  of  the  tumor.  The  tumor 
immediately  bulged  out  the  moment  the  tension  of  the  overlying  aponeurosis  was 
relieved.  The  division  of  the  sternomastoid  materially  aided  in  prolapsing  the  tumor, 
which  was  easily  enucleated  by  peeling  it  away  from  the  surrounding  tissues.  It  was 
then  lifted  out  of  the  wound,  and  a  broad  pedicle  attached  to  the  posterior  pharyngeal 
wall,  tonsil,  and  basilar  process  of  the  occipital  was  divided,  after  securing  a  number  of 
nutrient  vessels,  while  an  assistant  controlled  the  exposed  carotid,  at  a  lower  point, 
by  digital  pressure. 

"In  removing  the  growth  from  its  tonsillar  and  pharyngeal  attachments  the  pharynx 
was  opened  and  part  of  its  lateral  wall  was  excised.  The  fauces,  root  of  the  tongue,  and 
glottis  were  exposed.  The  opening  was  closed  with  silk,  and  after  the  extirpation  of  the 
parts  the  dislocated  larynx  and  other  organs  were  replaced  in  their  natural  position.  The 
mass  was  a  fibroma  and  weighed  4^  pounds.  The  manner  in  which  the  old  man  with- 
stood this  huge  traumatism  was  remarkable.  He  never  moved  or  uttered  a  word  of 
complaint,  and  his  slow  pulse  never  wavered  until  traction  was  made  upon  the  pharyn- 


NECK  287 

geal  pedicle.  In  this  case  it  must  be  recognized  that  we  were  dealing  with  a  stoic  of 
Spartan  type,  and  that  as  much  credit  is  due  to  his  heroism  as  to  the  cocain,  which  was 
only  used  to  anesthetize  the  skin  and  pharyngeal  attachment  of  the  tumor. 

"It  is  a  source  of  genuine  sorrow  and  regret  that  so  brave  a  man  should  not  have  been 
awarded  by  a  better  result  than  that  which  followed  this  extraordinary  exhibition  of 
psychic  fortitude.  After  lightly  packing  the  vast  cavity  left  in  the  neck  with  a  weak 
iodiform  gauze  and  reducing  the  length  of  the  cutaneous  incision  by  a  few  stitches,  the 
patient  was  sent  to  bed  and  thoroughly  stimulated.  His  pulse  was  slow  and  full,  and  he 
expressed  himself  as  being  very  comfortable.  He  was  well  until  about  seven  hours  after 
the  operation,  when  suddenly  and  without  any  warning  he  sank  into  a  syncopal  spell 
and  died  in  a  few  minutes,  before  any  assistance  could  be  rendered.  The  exact  cause  of 
death  was  never  ascertained,  but  it  is  presumed  that  death  was  caused  by  thrombus  or 
embolus." 

THE  LARYNX  AND  TRACHEA 

The  great  advantage  of  operating  without  inhalation  narcosis  in 
the  asphyxiating  diseases  of  the  larynx  and  trachea,  requiring  laryngo- 
tomy  and  tracheotomy,  led  to  the  early  trial  of  cocain  in  these 
operations. 

In  small  children,  suffering  from  diphtheria,  the  restlessness 
and  psychic  disturbance  of '  the  patient  contra-indicates  its  use ; 
here,  however,  incubation  has  practically  supplanted  tracheotomy 
altogether. 

But  in  operations  on  the  laryngotracheal  passages  in  adults  local 
anesthesia  has  become  the  routine  procedure,  and  its  success  in  these 
cases  is  as  fully  and  indisputably  established  as  it  is  in  the  removal 
of  an  ingrowing  toe-nail. 

Dr.  Matas  first  performed  tracheotomy  under  cocain  in  1889  in 
relieving  a  laryngeal  stenosis  from  abductor  paralysis,  and  since 
that  time  it  has  become  the  routine  anesthetic  in  our  practice.  We 
have  had  occasion  to  test  its  value  in  such  delicate  intralaryngeal 
operations  as  the  extirpation  of  the  vocal  bands  for  paralytic  steno- 
sis, using  a  Trendelenburg  tampon-cannula  to  prevent  the  entrance 
of  blood  into  the  lower  trachea  and  in  the  removal  of  foreign  bodies. 
In  these  operations  the  reflex  irritability  of  the  mucosa  must  also  be 
subdued  by  spraying  or  swabbing  the  larynx  directly  with  cocain 
solution. 

Tracheotomy,  high  or  low,  is  easily  performed  by  infiltration 
anesthesia  in  the  midline  of  the  neck,  and  needs  no  special  descrip- 
tion. It  is  unnecessary  to  infiltrate  the  trachea  before  opening  it, 
as  the  mucous  membrane  is  insensitive  to  pain,  but  will  excite  cough- 
ing as  soon  as  instruments  or  the  tracheal  tube  is  placed  within  it;  if 
for  any  reason  this  is  to  be  avoided  at  the  time,  the  opening  may  be 
retracted  and  a  spray  of  cocain  or  novocain  solution  gently  applied 
to  the  interior  before  the  tube  is  inserted. 


288  LOCAL   ANESTHESIA 

Alcohol  Injections  of  the  Internal  Laryngeal  Nerve  in  Tubercular 
Laryngitis. — By  this  method,  first  recommended  by  Hoffman,  Roth 
has  treated  33  cases  and  Levy  3  others.  In  Roth's  series  all  had  se- 
vere pain  on  swallowing,  which  had  resisted  all  other  methods  of 
treatment.  In  these  cases  a  painful  pathognomonic  spot  is  found  be- 
tween the  hyoid  bone. and  the  thyroid  cartilage  corresponding  to  the 
point  of  entrance  of  the  nerve. 

After  disinfection  of  the  skin  an  assistant  makes  pressure  upon 
the  opposite  side.  The  painful  point  is  then  located  with  the  finger, 
and  with  a  somewhat  blunt  needle,  though  an  ordinary  hypodermic 


Fig.  62. — Area  of  anesthesia  for  laryngectomy.    Over  double-lined  area  on  sides 
infiltration  is  more  liberal  and  is  carried  well  down  to  sternomastoid  muscle. 

will  do,  the  tissues  are  penetrated  to  a  depth  of  about  i  ^  cm.; 
the  needle  is  then  directed  upward  and  outward  (Fig.  60) ;  when  the 
nerve  is  reached  the  patient  complains  of  pain  radiating  toward  the 
ear.  For  the  accurate  location  of  this  nerve  see  innervation  of  the 
larynx,  page  282.  Then  i  to  2  c.c.  of  85  per  cent.,  alcohol,  warmed 
slightly  above  body  heat  (45°C.)  is  slowly  injected ;  some  immediate 
discomfort  is  produced  which  soon  subsides,  and  the  resulting 
analgesia  lasts  from  one  to  twenty-one  days,  one  week  being  the 
average. 

There  is  no  loss  of  cough  reflex  or  aspiration  of  food  following. 
There  seems  no  objection  in  repeating  the  injection  as  often  as  seems 


NECK  289 

necessary,  the  patients  often  requesting  that  this  be  done ;  there  seems 
no  diminution  of  the  effect  in  the  repeated  injections.  Both  sides 
may  be  injected  as  well  as  one,  but  when  one  injection  is  made  it  is 
always  over  the  nerve  which  seems  the  tenderest  on  pressure. 

In  all  operations  in  which  any  part  of  the  larynx,  trachea  or 
esophagus  is  to  be  opened  or  excised,  these  operations  should  be 
invariably  done  in  at  least  two  stages  in  all  cases  that  will  possibly 
permit  of  this  delay.  The  chief  source  of  danger  in  all  these  opera- 
tions is  that  the  inevitable  infection  which  always  occurs  around  the 
site  of  the  opening  into  the  trachea  or  esophagus  dissects  its  way  down 
along  the  cellular  planes  into  the  mediastinum  resulting  in  either  a 
mediastinitis  or  pneumonia  which  is  almost  invariably  fatal.  In  the 
case  of  a  resection  of  the  larynx  without  the  necessary  preliminary 
steps  the  sudden  and  continuous  entrance  of  cold  air,  and  often  dust- 
ladened,  into  the  lower  air  passages  may  result  in  pneumonia.  To 
avoid  this  last  danger  these  operations  in  addition  to  the  preliminary 
exposure  of  the  parts  should  have  a  small  tracheotomy  opening  made 
with  the  use  of  a  tracheotomy  tube  for  a  few  days  before  the  resection 
to  gradually  accustom  the  parts  to  do  without  the  moderating  influ- 
ence exerted  by  the  upper  respiratory  tract  upon  the  inspired  air. 
By  performing  all  operations  upon  these  parts  in  this  manner  the 
special  danger  which  has  heretofore  attended  these  procedures  is 
entirely  eliminated. 

Laryngectomy. — This  operation  should  be  invariably  done 
in  three  stages.  First,  the  thorough  exposure  of  the  larynx  and 
upper  part  of  the  trachea  with  packing  off  of  the  surrounding  tissues 
to  permit  an  impervious  wall  of  granulation  tissue  to  become  estab- 
lished which  will  prevent  any  extension  of  infection  into  the  sur- 
rounding tissues.  This  usually  requires  about  one  week.  During 
this  time  the  wound  is  kept  packed  to  keep  the  larynx  and  trachea 
isolated  in  the  center.  Second  stage.  The  trachea  is  opened  below 
the  proposed  field  of  operation  by  a  small  opening  and  a  tracheotomy 
tube  used  for  a  few  days  or  until  the  patient  becomes  accustomed  to 
the  condition.  Third  stage.  Removal  of  the  larynx  in  whole  or  part 
as  the  condition  requires.  When  done  in  this  way  the  operation 
presents  no  special  difficulties  and  is  quite  easily  done  and  should 
have  no  greater  mortality  than  any  other  ordinary  operation. 

The  area  of  anesthesia  is  shown  in  Fig.  62.  At  each  of  the  heavy 
dots  an  intradermal  wheal  is  established.  The  long  needle  is  entered 
through  these  points  and  the  intervening  subcutaneous  tissue  freely 

infiltrated.     On  the  sides  over  the  sternomastoid  muscles  this  infil- 
19 


290  LOCAL   ANESTHESIA 

tration  is  somewhat  more  liberal  and  carried  down  into  the  substance 
of  the  muscle  to  block  the  superficial  branches  of  the  cervical  plexus 
as  they  curve  forward  over  the  surface  of  this  muscle.  When 
properly  done  this  procedure  produces  an  anesthesia  of  the  skin  and 
superficial  parts  within  the  injected  area.  The  incision  is  made  in 
the  midline  from  the  hyoid  bone  down  almost  to  the  sternal  notch 
and  carried  down  to  the  sterno-hyoid  muscles,  the  superficial  tissues 
are  retracted  to  either  side ;  with  a  little  blunt  dissection  the  interval 
between  the  larynx  and  trachea  in  the  midline  and  the  muscles  on 
the  side  is  identified  the  finger  gradually  working  its  way  down  until 
the  position  of  the  great  vessels  is  clearly  outlined  by  palpation.  The 
needle  is  then  slipped  down  alongside  the  finger  and  this  interval 
infiltrated  at  the  upper  and  lower  extremities  of  the  field  and  in  the 
middle,  this  procedure  is  repeated  on  the  opposite  side.  The  tissues 
just  over  the  trachea  immediately,  around  the  isthmus  of  the  thyroid 
gland  are  also  infiltrated.  This  completes  the  anesthesia.  The 
sterno-hyoid  and  sterno-thyroid  muscles  are  now  divided  or  removed 
as  preferred  but  if  the  contemplated  resection  is  not  to  be  extensive 
an  attempt  should  be  made  to  preserve  some  part  of  these  muscles 
for  their  subsequent  aid  in  deglutition  this  can  be  done  particularly 
with  the  sterno-hyoid  by  allowing  its  lateral  attachments  to  the 
hyoid  bone  to  remain  and  retracting  the  muscle  quite  freely  and 
fixing  it  in  the  lateral  tissues  with  a  stitch.  The  isthmus  of  the 
thyroid  gland  is  then  divided  and  the  two  lobes  of  the  gland  pushed 
off  into  the  wound  on  either  side.  All  other  tissues  overlying  the 
proposed  field  of  resection  are  similarly  divided  and  pushed  well  to 
one  side  leaving  the  larynx  and  trachea  freely  exposed  back  to  the 
vertebral  column.  The  wound  is  well  packed  to  maintain  the  parts 
in  this  position  and  dressed  as  occasion  requires.  When  granulations 
are  well  established  a  tracheotomy  opening  is  made  and  a  tube  in- 
serted, this  usually  requires  no  anesthesia  but  can  if  preferred  be 
lightly  infiltrated  before  incision.  The  violent  coughing  which 
usually  accompanies  the  first  insertion  of  the  tube  can  be  greatly 
lessened  by  using  a  10  per  cent,  cocain  spray  down  the  throat  having 
the  patient  inspire  deeply  during  the  procedure  and  waiting  a  few 
minutes  following  this  before  opening  the  trachea.  After  a  few 
days  the  resection  is  undertaken  and  requires  very  little  anesthesia. 
The  thyro-hyoid  membrane  is  infiltrated  on  each  side  just  below  the 
cornu  of  the  hyoid  bone  where  the  superior  laryngeal  nerve  enters; 
similar  injections  are  made  at  the  lower  extremity  of  the  field  between 
the  trachea  and  esophagus  where  the  recurrent  laryngeal  nerve 


NECK  291 

passes  upward.  This  completes  the  anesthesia  and  the  resection 
can  be  proceeded  with.  The  granulation  tissue  on  the  lateral  walls 
of  the  wound  is  not  usually  sensitive  unless  roughly  handled  and 
can  be  anesthetised  if  necessary  by  passing  a  fine  needle  beneath 
it  at  several  points  and  infiltrating  the  underlying  tissues.  If  the 
larynx  is  to  be  completely  removed  it  is  usually  best  to  first  divide 
the  trachea  below  the  field  and  draw  its  lower  end  slightly  forward 
and  secure  it  to  prevent  aspiration  of  blood  and  mucous. 

With  slight  modifications  in  the  technic  such  as  suggest  them- 
selves this  same  general  plan  of  procedure  can  be  applied  to  opening 
or  resecting  the  esophagus. 

In  any  of  the  above  procedures  where  it  is  not  possible  to  adopt 
the  two-  or  three-stage  operation  the  subsequent  dangers  are  greatly 
lessened  by  keeping  the  patient's  head  and  shoulders  lowered  by 
elevating  the  foot  of  the  bed  which  favors  drainage  away  from  the 
mediastinum. 

GOITER 

"One  of  the  most  convincing  proofs  of  the  great  extension  of  local 
anesthesia  in  the  surgery  of  the  neck  has  been  given  by  Kocher  and 
his  followers  in  their  numerous  operations  for  the  cure  of  goiter. 
When  we  consider  that  the  statistics  of  operations  for  goiter,  as  fur- 
nished by  the  clinics  of  Kocher,  Roux,  the  Reverdins,  Socin,  Bruns, 
Mikulicz,  Burkhardt,  and  other  surgeons  who  practice  in  the  great 
zone  of  goiter  infection  in  Europe,  amount  to  thousands  of  cases,  and 
that  since  the  value  of  cocain  as  an  anesthetic  was  first  established 
by  Kocher  (who  alone  claims  a  large  majority  of  many  thousand 
goiter  cases  as  cocain  operations)  local  anesthesia  has  become  a 
routine  practice  in  such  cases,  we  will  realize  what  a  large  slice  of 
surgical  territory  has  been  wrested  from  the  domain  of  general  anes- 
thesia in  this  region  alone"  (Matas). 

When  we  realize  that  those  who  have  had  the  greatest  experience 
with  these  operations  unconditionally  oppose  general  anesthesia  we 
are  impressed  with  the  importance  of  considering  the  advantages  of 
local  anesthesia  in  these  cases.  Aside  from  the  general  objections 
to  general  anesthesia  the  special  objections  are:  Postoperative  com- 
plications of  a  toxic  character  are  more  likely  to  occur  due  to  degenera- 
tive changes  in  the  gland.  The  heart  is  often  badly  involved  in 
these  cases,  particularly  in  the  exophthalmic  type  and  is  subjected 
to  considerable  additional  strain  from  the  anesthetic.  The  blood- 
pressure  is  often  considerably  reduced  in  bad  cases  and  may  collapse 
during  the  administration  of  the  anesthetic  or  after  its  withdrawal. 


2Q2  LOCAL   ANESTHESIA 

The  trachea  is  often  softened,  compressed  or  distorted  and  may 
collapse  under  the  general  anesthetic.  The  increased  risk  of  injury 
to  the  recurrent  laryngeal  nerve  from  inclusion  within  the  grasp  of 
forceps  or  ligatures  or  even  being  divided.  These  accidents  are  less 
likely  to  occur  in  the  conscious  patient  and  should  they  occur  the 
immediate  disturbance  in  phonation  will  attract  attention  and  the 
damage  may  be  corrected. 

Hemorrhage  is  markedly  reduced  under  local  anesthesia,  permit- 
ting a  more  careful  anatomical  dissection  which  lessens  the  danger 
of  possible  accidents.  The  postoperative  vomiting  following  the 
general  anesthetic  aside  from  the  danger  of  soiling  the  dressings 
may  be  decidedly  painful  and  the  effort  may  cause  secondary 
hemorrhage. 

The  strain  on  the  kidneys  is  decidedly  less  under  local  anesthesia 
and  this  is  particularly  an  advantage  in  exophthalmic  cases  where 
there  is  usually  an  increase  in  toxic  symptoms  immediately  following 
operation,  here  the  system  can  be  flushed  by  large  quantities  of 
water  given  by  mouth  when  the  need  is  greatest. 

There  is  less  operative  and  psychic  shock  as  the  patient  is  likely 
to  regard  an  operation  under  local  as  less  serious  than  one  under 
general  anesthesia. 

Simple  colloid  goiter,  unless  excessively  large,  is  comparatively 
easily  removed  by  local  anesthesia.  Here  we  do  not  have  the  great 
nervous  tension,  with  the  psychic  effect  of  fear,  to  contend  with  as 
seen  in  the  exophthalmic  type.  These  goiters  may  involve  one  or 
both  lobes  of  the  gland.  The  principal  nerve-supply  is  from  the 
cervical  plexus,  the  nerves  running  forward  from  the  posterior  edge  of 
the  sternomastoid.  Consequently,  most  of  our  anesthetic  solution  is 
distributed  at  this  point,  also  creating  a  light  zone  of  anesthesia 
around  the  gland  (Figs.  63  and  64). 

First  produce  a  "station"  in  the  skin  on  the  outer  side  of  the 
gland,  then  the  long  needle  can  be  passed  down  to  the  posterior 
border  of  the  sternomastoid  and  an  area  of  infiltration  created  at  this 
point,  care  being  taken  not  to  penetrate  too  deeply  for  fear  of  injury 
to  the  carotid  and  jugular,  which  He  just  in  front;  from  this  point  the 
needle  should  be  directed  around  the  gland,  subcutaneously  injecting 
as  it  is  advanced,  first  above  and  then  below,  the  margin  of  the 
tumor,  injecting  as  you  go.  In  case  only  one  lobe  is  involved 
a  station  is  now  produced  in  the  skin  of  the  midline  over  the  tra- 
chea, and  a  free  injection  made  in  this  position  from  the  skin  down 
to  the  trachea  as  the  nerves  of  the  opposite  side  lap  over  the  midline. 


NECK 


293 


Fig.  63. — Points  of  injection  and  area  of  anesthesia  for  thyroidectomy.     (From  Braun.) 


-• 


Fig.  64. — Points  of  injection  and  area  of  anesthesia  for  thyroidectomy.     (From  Braun.) 


2Q4  LOCAL    ANESTHESIA 

In  the  event  of  both  lobes  being  involved  this  last  injection  can 
be  very  light  and  made  principally  in  the  deeper  structures.  An 
injection  is  then  made  on  the  outer  side  of  the  opposite  lobe  over  the 
posterior  border  of  the  sternomastoid  similar  to  the  first  side. 

If  the  tumor  is  very  large,  stations  may  have  to  be  established 
above  and  below  to  properly  reach  the  entire  circumference  of  the 
growth. 

The  skin  incision  is  usually  made  across  the  most  prominent  part 
of  the  gland,  either  transverse  or  curved,  according  to  the  shape  of  the 
growth,  and  the  muscles  in  the  midline  retracted.  When  working 
with  local  anesthesia  it  is  better  to  attack  the  isthmus  of  the  gland 
first;  the  capsule  is  peeled  back  and  the  isthmus  divided,  preferably, 
between  clamps;  a  syringeful  of  solution  may  have  to  be  injected 
thoroughly  under  the  isthmus  over  the  trachea  before  this  can  be 
done.  After  the  isthmus  is  divided  the  gland  is  rolled  out;  this  early 
division  of  the  isthmus  and  its  separation  from  the  trachea  relieve 
the  traction  upon  this  structure  in  manipulation  elsewhere,  which 
might  otherwise  cause  the  patient  to  complain.  As  the  gland  is 
rolled  out  the  posterior  capsule  and  underlying  tissues  will  need 
infiltration.  This  is  best  done  by  making  gentle  traction  upon  the 
gland  when  a  finger  can  be  directed  under  it  from  the  tracheal  side 
and  the  various  parts,  particularly  the  large  vessels,  identified.  A 
long  needle  can  now  be  directed  up  alongside  of  the  finger  and  the 
tissues  behind  the  gland  injected  especially  toward  the  upper  and 
lower  poles,  about  ^  ounce  of  solution  being  distributed  at  each  of 
these  points.  This  usually  completes  any  injections  necessary  and 
ordinarily  makes  the  operation  quite  easy.  In  case  the  isthmus  is 
not  divided  first  as  described  above  these  deep  injection  can  be  made 
from  the  side  after  freely  retracting  the  muscles  and  slightly  elevating 
the  gland. 

The  capsule  is  pushed  back  from  the  gland  as  it  is  delivered;  the 
superior  pole  is  caught  between  clamps  and  divided  and  later  ligated, 
thus  leaving  a  portion  of  the  gland  at  this  point  with  the  capsule, 
which  is  left  behind,  containing  the  parathyroid  bodies.  The  rest  of 
the  operation  is  simple.  The  opposite  side,  if  involved,  is  removed 
the  same  way;  if  not,  the  isthmus  is  ligated. 

In  closing  the  wound  the  muscles  in  the  midline  should  be  replaced 
in  nearly  their  same  position  and  the  platysma  sutured  separately, 
being  careful  not  to  include  the  platysma  or  any  of  the  deeper  muscles 
in  the  skin  suture,  as  they  will  be  bound  together  this  way  in  the 


NECK 


295 


resulting  cicatrix,  which  will  later  pull  the  skin  up  and  down  in  an 
unpleasant  way  whenever  these  muscles  act. 

In  making  the  first  incision  the  skin  and  platysma  can  be  divided 
at  different  levels,  which  further  obviates  the  above  result. 

A  small  rubber  drain  is  left  in  the  wound. 

Exophthalmic  Goiter. — In  this  type  of  goiter  we  are  concerned 
more  especially  with  the  condition,  the  result  of  the  hyperthyroi- 
dism  than  with  the  local  condition  itself. 

The  extremely  nervous  and  psychic  state  of  the  patient  often 
associated  with  grave  cardiac  changes  makes  the  condition  one  of 
extreme  danger  when  operating  by  any  method  of  anesthesia.  We 
believe,  however,  that  many  of  these  cases  are  better  operated  by 
local  methods  of  anesthesia  than  by  general  inhalation  narcosis, 
using  in  these  cases  a  slightly  larger  preliminary  dose  of  morphin 
and  scopolamin,  giving  %  gr.  of  the  former  and  )•{ QO  gr-  of  the  latter 
one  hour  beforehand,  or  ^  gr.  of  pantopon  with  the  scopolamin. 

This  very  effectually  relieves  the  fear  and  dread  so  terrifying  in 
these  patients,  and  produces  a  state  of  apathy  in  which,  if  the  opera- 
tion is  carefully  and  gently  performed  with  a  thorough  observance 
of  the  anesthetic  technic  and  no  pain  inflicted,  the  patient  is  enabled 
to  leave  the  table  in  much  better  condition  than  after  a  general 
anesthetic. 

The  best  method  of  dealing  with  these  patients  has  been  the  sub- 
ject of  much  thought  and  investigation  on  the  part  of  many  operators, 
and  has  resulted  in  a  voluminous  literature.  Dr.  Crile  at  one  time 
advocated  local  methods  of  anesthesia  exclusively,  but  now  uses  a 
combined  method,  not  letting  the  patient  know  when  operation  is 
to  be  performed.  Various  aromatic  substances  are  administered 
daily  on  an  inhalation  cone  as  a  presumable  part  of  the  treatment, 
which  is  done  in  the  patient's  room.  On  the  day  of  the  operation 
anesthetics  are  gradually  substituted  without  the  patient's  knowledge 
until  narcosis  is  produced;  the  patient  is  then  removed  to  the  operat- 
ing room.  It  is  not  necessary  that  this  anesthesia  be  very  profound, 
as  the  field  is  injected  freely  with  local  anesthetic  solutions  which 
prevent  the  transmission  of  painful  impressions.  The  general  anes- 
thesia is  used  only  to  control  the  psychic  state  of  the  patient;  it  is, 
consequently,  only  necessary  to  produce  a  subconscious  state.  (See 
chapter  on  Combined  Methods  of  Anesthesia  for  a  further  considera- 
tion of  this  method.) 

The  technic  of  the  operation  is  the  same  as  that  given  for  colloid 
goiter. 


296  LOCAL  ANESTHESIA 

We  have  not  had  occasion  to  resort  to  the  combined  method  of 
anesthesia  in  these  cases  very  often,  as  we  have  found  local  anes- 
thesia alone  was  usually  very  satisfactory,  but  there  is,  of  course,  no 
objection  to  allowing  a  few  whiffs  of  ether  or  chloroform  or  even  alco- 
hol on  a  cone  should  it  appear  advisable. 

We  do  not  mean  to  convey  the  impression  that  all  these  cases 
are  operated  on  by  us  under  local  anesthesia,  but  the  majority  of 
them  are.  We  could  relate  numerous  clinical  illustrations,  but  the 
following  brief  review  of  a  rather  severe  case,  operated  on  by  the 
author,  will  suffice. 

Exophthalmic  goiter.  Trahan,  aged  twenty-six.  Entered  Ward  9  July  26,  1008. 
Trouble  of  two  years'  duration.  Markedly  emaciated  and  weak;  prominent,  staring 
eyes,  with  a  pulsating  tumor  as  large  as  the  fist  in  the  thyroid  region.  Heart  enormously 
dilated,  weak,  rapid,  and  irregular,  with  murmurs  over  the  entire  chest.  Respiration 
rapid  and  irregular,  pulse  very  irregular  and  weak,  varied  from  98  to  140.  Temperature 
from  99°  to  ioi°F.  The  right  lobe  and  isthmus  were  removed;  the  left  lobe,  being  but 
slightly  affected,  was  not  disturbed.  Anesthesia  was  perfect  (technic  same  as  for  colloid 
goiter).  The  patient  conversed  with  us  during  the  procedure,  and  rendered  assistance 
by  turning  his  head  in  different  positions.  He  winced  once  or  twice  when  we  pulled  on 
the  trachea  in  lifting  the  gland  from  its  bed.  He  left  the  table  in  good  condition, 
apparently  not  affected  by  the  operation.  His  progress  for  a  few  days  was  much  dis- 
turbed by  a  weak  and  rapid  heart,  but  he  finally  made  a  good  recovery  and  left  the  hos- 
pital August  2oth.  He  wrote  me  a  letter  later  that  he  was  entirely  well. 

These  cases  are  particularly  suited  to  local  anesthesia,  and  I  doubt 
if  this  particular  one  could  have  stood  the  operation  with  a  general 
anesthetic. 

It  is  hardly  the  purpose  of  a  book  of  this  kind  to  enter  into  a  dis- 
cussion of  the  many  conditions  arising  in  those  patients  which  have 
to  be  considered  in  selecting  the  time  for  operation,  also  the  pre- 
paratory and  postoperative  treatment,  all  of  which  are  found  in  the 
general  surgeries,  and  do  not,  as  a  rule,  differ  in  any  respect,  whether 
the  operation  is  done  under  general  or  local  anesthesia. 

There  is,  however,  a  procedure  which  I  would  like  to  speak  of  here, 
either  as  a  palliative  operation  or  as  one  preparatory  to  a  radical  pro- 
cedure; namely,  ligation  of  the  thyroid  vessels.  This  operation, 
while  done  before,  owes  much  of  its  popularity  to  the  Mayos.  Fol- 
lowing the  ligation  of  the  vessels  a  Colloid  degeneration  takes  place 
in  the  gland  with  subsidence  of  the  symptoms  of  hyper thyroidism. 

After  two  or  three  months'  delay  the  radical  removal  of  the  parts 
of  the  glands  affected  can  be  undertaken  with  no  greater  diffi- 
culties than  those  attending  ordinary  goiter.  As  a  preliminary  step 
in  the  handling  of  all  severe  cases  this  should  be  borne  in  mind,  as  the 
procedure  is  very  easily  carried  out  and  involves  practically  no  risk 


NECK  2Q7 

under  local  anesthesia,  offers  quite  a  boon  to  these  patients,  and 
should  prove  a  decided  factor  in  reducing  the  mortality  rate  in  these 
cases. 

The  following  is  from  an  article  by  Dr.  Chas.  H.  Mayo,  which 
appeared  in  the  "Annals  of  Surgery,"  December,  1909: 

"The  earliest  ligation  of  vessels  as  an  operation  for  the  relief 
of  goiter  is  credited  to  Wolfler.  Our  experience  with  this  procedure 
covers  over  200  operations,  and,  with  the  results  obtained  by  this 
method,  we  consider  that  the  ligation  of  certain  thyroid  arteries  and 
veins,  and  at  times  a  portion  of  the  gland,  seems  indicated  in  some 
cases  of  hyperthyroidism. 

"  First.  In  those  suffering  from  mild  symptoms  of  hyperthyroid- 
ism, and  those  in  whom  the  diagnosis  is  made  early,  possibly  before 
the  less  important  eye  symptoms  or  even  goiter  is  present.  In  cases 
which  are  hardly  severe  enough  to  warrant  a  thyroidectomy  the 
ligation  of  the  vessels  will  often  produce  a  cure  in  a  few-  weeks  with 
but  little  risk  and  without  the  necessity  of  special  medication. 

"Second.  Ligation  is  indicated  in  that  larger  group  of  acute, 
severe  exophthalmic  goiters,  and  very  sick  patients,  who,  having 
exhausted  all  forms  of  treatment,  are  now  suffering  with  various  sec- 
ondary symptoms— dilatation  and  degeneration  of  the  heart,  fatty 
liver,  soft  spleen,  diseased  kidneys,  which  have  resulted  from  the 
chronic  toxins,  as  seen  in  the  later  stages  of  Graves'  disease — changes 
which,  after  all,  are  the  final  cause  of  death.  This  operation  is  of  par- 
ticular value  in  those  cases  with  a  marked  pulsation  and  peculiar 
thrill  of  the  superior  thyroid  arteries. 

"All  severe  cases  of  hyperthyroidism  when  suffering  from  edema, 
ascites,  dilatation  of  the  heart,  diarrhea,  or  gastric  crisis  of  vomiting 
should  be  under  observation  for  a  short  time  at  least,  and  some  of 
them  for  a  considerable  period  of  time,  to  improve  their  condition, 
if  possible,  before  even  a  ligation  be  attempted.  There  is  a  time 
in  the  progress  of  these  cases  when  terminal  degeneration  of  essential 
organs  has  advanced  so  far  that  they  are  no  longer  curable.  When 
surgery  is  applied  as  a  last  resort  it  may  be  possible,  by  using  some 
special  great  dexterity  and  care,  to  remove  part  of  the  gland  without 
an  immediate  fatal  result.  While  the  disease  may  be  checked,  these 
patients  are  seldom  sufficiently  benefited  to  warrant  the  immoderate 
risk  of  an  extirpation.  On  the  other  hand,  at  such  times  many  cases, 
which  have  at  first  appeared  to  be  unfavorable  subjects,  will  so 
for  improve  under  symptomatic  treatment,  aided  by  rest,  hygiene, 
#-rays,  etc.,  as  to  become  suitable  operative  subjects  at  a  later  period. 


2Q8 


LOCAL   ANESTHESIA 


It  is  in  this  class  of  cases  that  ligation  as  a  preliminary  procedure  is  of 
great  value.  The  relative  safety  of  ligation,  as  compared  with  that 
of  thyroidectomy,  may  lead  the  operator  to  accept  as  surgical  risks 
patients  so  far  advanced  in  the  disease  as  to  have  but  little  prospect 


FIG.  65. — Ligation  of  the  superior  thyroid  vessels.     (C.  H.  Mayo.) 

of  cure.  In  operating  upon  these  cases  the  surgeon  should  use  his 
judgment  as  to  the  time  and  method  of  operation  and  the  anesthesia 
to  be  used  from  observations,  according  to  the  improvement  manifest 
under  preparatory  treatment. 


NECK  2Q9 

"Operation. — A  transverse  incision  gives  the  best  working  space 
as  well  as  the  least  disfiguring  scar.  It  is  made  2%  inches  in  length, 
crossing  the  central  part  of  the  thyroid  cartilage.  The  incision 
should  be  made  in  a  natural  skin  crease  if  possible,  and  should  in- 
clude the  platysma  myoides,  this  one  incision  being  better  than  two 
lateral.  The  inner  border  of  the  sternomastoid  is  tracted  laterally. 
This  exposes  the  omohyoid  muscle,  which  is  tracted  up  and  in 
toward  the  midline.  Beneath  this  muscle  is  the  upper  pole  of  the 
gland  with  the  superior  thyroid  artery  and  vein  (Fig.  65). 

"The  ligating  material  is  linen,  passed  by  an  aneurysm  needle. 
Should  a  vein  be  pierced  and  a  hemorrhage  follow  the  placing  of  the 
ligature,  it  is  tracted  upon,  and  a  second  loop  is  passed  around  includ- 
ing more  tissue.  In  most  cases  this  is  preferable  to  a  more  generous 
incision  with  freer  dissection.  The  veins  are  purposely  included  to 
secure  venous  obstruction,  the  free  anastomosis  within  the  gland 
capsule  making  this  of  advantage.  One  need  not  fear  the  ligation  of 
a  nerve  in  this  location,  as  the  inferior  or  recurrent  laryngeal  is  below. 
The  wound  is  closed  by  a  subcuticular  suture  without  drainage. 

"The  location  of  the  ligation  at  the  pole  of  the  gland  is  important, 
as  in  one  of  our  cases  in  which  the  superior  thyroid  arteries  had  been 
previously  ligated  at  a  point  where  they  were  given  off  from  their 
origin  at  the  external  carotid  there  was  but  partial  and  temporary  re- 
lief. At  the  second  operation  we  found  a  reversal  of  the  circulation 
in  the  large  inner  branch  anastomosing  with  the  inferior  thyroid, 
and  in  the  upper  part  of  the  gland  the  circulation  was  but  little 
reduced. 

"In  the  large  hard  glands  of  hyperthyroidism,  where  some  rever- 
sion has  occurred  with  colloid  deposit,  ligation  is  not  indicated. 
The  changes  in  the  gland  after  ligation  are  most  interesting.  There 
is  a  change  from  the  great  increase  in  cell  development  back  to  the 
condition  of  simple  goiter.  This  is  produced  by  a  simple  exfoliation 
of  cells,  and  does  not  resemble  the  degenerative  changes  which  are 
found  in  the  glands  removed  in  the  late  stages  of  Basedow's  disease 
or  those  in  which  serum  treatment  has  been  used.  In  both  of  these 
there  is  a  true  cytolysis  or  chemical  destruction  of  the  cell. 

"While  many  patients  reported  indefinite  gain  in  weight,  there 
were  68  cases  in  which  an  accurate  report  was  given,  showing  that 
62  patients  gained  an  average  of  20  ^  pounds  from  three  to  five 
months  after  operation.  If  cases  were  excluded  that  were  about 
normal  weight  at  the  time  of  operation  the  average  gain  would  exceed 


300  LOCAL  ANESTHESIA 

this.     Six  patients  lost  an  average  of  6  pounds.     Most  of  these  were 
but  little  reduced  at  the  time  of  the  operation. 

"In  the  majority  of  cases  the  ligation  is  made  as  a  definite  step 
in  a  graduated  operation  to  reduce  excessive  secretion  of  the  gland, 
and  some  of  the  reported  cases  are  yet  to  be  operated  upon  for  the 
removal  of  part  of  the  gland  as  a  secondary  procedure.  Some  of  the 
patients  in  this  series  consider  themselves  too  well  at  present  to 
undergo  another  operation,  and  will  probably  do  so  only  under  the 
stress  of  a  relapse  of  their  symptoms,  when  it  may  be  advisable  to 
ligate  the  right  inferior  thyroid  artery  as  a  second  step  toward  thy- 


FIG.  66. — Line  of  infiltration  anesthesia  for  double  ligation  of  superior  laryngeal  artery. 
On  each  side  the  injection  is  made  freely  into  the  deep  tissues. 

roidectomy.  We  found  this  procedure  of  value  in  9  cases.  On 
several  occasions,  because  of  the  various  seemingly  urgent  reasons  in- 
volving the  safety  of  the  patient,  we  deemed  it  advisable  to  convert 
a  thyroidectomy  into  a  ligation  of  vessels." 

For  the  ligation  of  the  superior -thyroid  arteries  the  area  of  the 
superficial  anesthesia  is  shown  in  Fig.  66.  After  the  skin  has  been 
passed,  deeper  injections  are  made  into  the  parts  before  their  dissec- 
tion, making  these  injections  rather  liberally  around  the  superior 
poles,  which  must  be  well  blocked  before  being  ligated. 

In  the  preceding  pages  I  have  endeavored  to  point  out  some  of 
the  uses  of  local  anesthesia  in  the  major  surgery  of  the  neck.  It  is 


NECK  301 

only  fair  now  to  state  that  there  still  remain  conditions  in  which  it 
is  an  impracticable  and  unsatisfactory  mode  of  anesthesia.  This  is 
particularly  true  of  all  atypical  operations  in  which  the  lesions  and 
the  limits  of  the  field  of  operation  are  ill-defined,  as  in  multiple 
lymphatic  tuberculosis,  where  the  chains  of  infected  glands  are  held 
fast  to  the  periglandular  tissues  by  dense  adhesions. 

In  the  removal  of  chains  of  malignant  lymph-nodes  the  same 
objections  hold  with  still  greater  force,  and  a  general  anesthetic 
becomes  necessary.  Malignant  tumors,  unless  well  defined,  should 
rarely  if  ever  be  operated  upon  by  infiltration  in  any  region,  and  when 
done  the  Hackenbuch  plan  should  be  followed.  These  remarks  do 
not  refer  to  the  application  of  regional  methods  for  this  purpose, 
which  can  always  be  employed. 


CHAPTER  XVI 
THE  THORAX  AND  BACK 

IN  the  major  surgery  of  this  region  the  local  infiltration  and 
neuroregional  methods  have  yielded  excellent  results.  Except  in 
children  and  very  nervous  patients,  many  of  the  commonly  per- 
formed operations  can  be  as  easily  and  often  more  safely  performed 
by  these  methods  than  with  general  anesthesia.  This  is  especially 
the  case  with  empyema  and  hepatic  abscess,  where  the  patient  is 
often  exhausted  by  profound  sepsis  as  well  as  the  antecedent  dis- 
eases (pneumonia,  tuberculosis,  or  dysentery),  and  from  dyspnea 
due  to  the  encroachment  upon  the  pulmonary  area  by  these  accu- 
mulations. In  bad  cases  of  this  kind  the  administration  of  an  anes- 
thetic may  be  extremely  hazardous  or  even  absolutely  contra-indi- 
cated. Here  local  anesthesia  has  proved  of  great  value  and  should 
always  be  given  the  preference.  The  infiltration  and  operation  must, 
however,  be  gently  and  delicately  executed.  Any  undue  traction  or 
pressure  on  the  surrounding  sensitive  parts  will  give  pain  and  cause 
the  patient  to  complain  and  lose  confidence  in  the  promise  of  a  pain- 
less procedure.  Serious  operations  in  the  depths  of  the  thoracic 
cavity  requiring  extensive  manipulation  of  the  circulatory  and  respira- 
tory organs  difficult  at  best  under  general  anesthesia  are  not  likely 
to  ever  prove  attractive  under  local.  The  psychic  effect  of  the 
disturbance  of  these  parts  must  make  the  procedure  inadvisable 
upon  conscious  patients. 

The  nerves  of  the  thorax  are  principally  the  intercostals  (anterior 
divisions  of  the  dorsal  nerves).  The  upper  six,  with  the  exception  of 
the  first  and  intercostohumeral  branch  of  the  second,  supply  the 
chest  wall  alone;  the  lower  six,  after  being  distributed  to  the  parietes 
of  the  chest  for  the  anterior  half  of  their  course,  are  distributed  to 
the  abdominal  wall,  the  last  one  (twelfth  dorsal)  sending  a  filament 
as  low  down  as  the  hip.  In  the  intercostal  spaces  these  nerves  lie 
just  below  the  arteries,  near  the  lower  border  of  the  ribs,  about  the 
middle  of  their  course,  near  the  anterior  axillary  line ;  each  gives  off  a 
lateral  cutaneous  branch,  which  pierces  the  muscles  to  the  subcuta- 
neous tissues  and  divides  into  anterior  and  posterior  branches,  the 
anterior  branch  running  forward  as  far  as  the  sternum,  the  posterior 

302 


THE    THORAX   AND   BACK 


303 


coursing  backward  in  the  skin  of  this  region  (Fig.  67).     In  the  inter- 
costal spaces  the  nerves  lie  first  between  the  pleura  and  internal 


lesser  splanchn 


t  nerve 
'aeus  nerve 

<hrenic  nerve  X 

left  subclavian  artery 

ternal  mammary  artery  X 
bronchial  arteries 
•current  nerve 

'ulmonary  branches 
of  left  vagus  nervt 


left  bronchus  X 


oesophageal  art 

igeal  ch 
vagus  i 

iphagus 


vesophageal  chords 
of  left  vagus  nerve  X 


coeliac  artery  X 
tinal      superior  mesenteric  art.  X 

Fig.  67.— The  large  vascular  and  nervous  trunks  of  the  posterior  thoracic  wall  as 
viewed  from  in  front  and  somewhat  from  the  right.  *  =  Location  of  twelfth  rib. 
**  =  Communication  between  azygos  and  hemi-  azygos  veins.  (Sobotta  and  McMurrich.) 

intercostal  muscle,  then  between  the  two  intercostals  to  near  the 
middle  of  the  ribs,  when  they  continue  their  course  between  the 


LOCAL   ANESTHESIA 

fibers  of  the  internal  intercostal  muscle.  In  the  anterior  half  of 
this  course  the  nerves  lie  well  under  the  overlapping  lip  of  the  rib 
and  often  have  to  be  hooked  out  to  be  brought  into  view,  in  the 
posterior  half  of  this  course  they  are  not  so  deeply  situated  and  are 
readily  seen  upon  opening  the  intercostal  spore. 

The  twelfth  intercostal  unlike  the  other  intercostals  gradually 
draws  away  from  the  rib  so  that  at  about  the  tip  of  the  twelfth  rib 


Fig.  68. — Areas  of  distribution  of  supraclavicular  nerves  overlapping  field  of  anterior 
thoracic  nerves.  Area  of  postthoracic  seen  laterally:  i,  Line  of  anesthesia  for  exposing 
brachial  plexus;  2,  line  of  anesthesia  over  clavicle  for  blocking  supraclavicular  nerves; 
long  needle  is  entered  over  middle  of  the  clavicle  and  directed  subcutaneously  toward 
each  end  of  the  bone;  3,  deep  infiltration  of  pectoral  muscles  from  point  near  middle  of 
clavicle  to  axillary  margin. 

it  lies  about  i  inch  below  and  gives  off  its  lateral  cutaneous  branch 
much  further  back  than  the  other  intercostals.  In  the  midline  of 
the  chest  the  nerves  of  each  side  overlap  for  some  little  distance. 
In  the  upper  and  lateroposterior  regions  of  the  thorax  the  branches 
of  the  brachial  plexus  and  supraclavicular  nerves  are  distributed  to 
these  parts. 

In  front  the  supraclavicular  nerves  send  branches  to  the  skin  of 
the  thorax  nearly  as  far  as  the  nipple;  the  external  or  supra-acromial 
branches  supply  the  skin  on  the  upper  and  back  part  of  the  shoulder; 


THE   THORAX   AND  BACK  305 

these  branches  pass  obliquely  across  the  outer  surface  of  the  trapezius 
and  the  acromion. 

In  addition  to  the  above,  branches  of  the  anterior  thoracic  nerves 
supply  the  entire  area  covered  by  the  pectoral  muscles,  though  on  a 
deeper  plane ;  they  send  branches  through  to  the  surface. 

On  the  side  of  the  chest  the  posterior  or  long  thoracic  extends 
downward  to  the  lowest  digitations  of  the  serratus  magnus. 

The  typical  course  of  an  intercostal  nerve  is  seen  in  Fig.  8 1 ,  and 
in  Fig.  68  is  seen  the  area  in  which  the  supraclavicular  anterior  and 
posterior  thoracic  nerves  intermingle  in  their  distribution  with 
branches  from  the  intercostal. 


Fig.  69. — Shows  line  of  anesthesia  and  points  for  entering  long  needle  for  blocking  inter- 
costal nerves  at  angle  of  ribs. 

In  the  scapula  region  behind,  the  thoracic  wall  is  overhung  by 
this  bone  and  its  attached  muscles,  which  will  have  to  be  dealt  with 
in  any  procedure  which  involves  the  chest  wall  at  this  point;  however, 
this  is  not  often  the  site  of  surgical  intervention. 

It  will  be  seen  from  the  above  and  a  study  of  Fig.  68,  which  repre- 
sents diagrammatically  the  intermingling  of  the  areas  of  distribu- 
tion of  these  nerves,  that  any  methods  of  regional  anesthesia,  when 
applied  to  the  anterior  chest  wall  above  or  the  lateral  chest  wall  be- 
hind, must  deal  with  nerves  which  enter  the  field  from  a  variety  of 
directions. 

To  block  the  intercostal  nerves  over  a  wide  area  of  distribution  is 
best  done  behind  near  the  angle  of  the  ribs,  where  they  approach 


306  LOCAL   ANESTHESIA 

close  to  the  posterior  wall  and  before  the  lateral  branches  are  given 
off,  though  this  can  be  done  at  any  point  of  their  course. 

A  vertical  line  of  cutaneous  anesthesia  is  carried  down  the  back 
over  the  angle  of  the  ribs,  as  seen  in  Fig.  69;  the  scapula  is  carried 
well  forward  and  the  finger  locates  the  rib;  a  long  fine  needle  is  now 
passed  down  to  the  interval  between  the  ribs;  this  is  best  done  ob- 
liquely from  below;  with  a  finger  pressed  firmly  on  the  rib,  the  needle 
is  made  to  pass  upward  and  inward,  injecting  as  it  is  advanced  until 
it  strikes  the  bone;  it  is  then  pushed  upward  and  inward  for  about  i 
cm.  further  into  the  intercostal  space  above,  and  this  freely  infil- 
trated. This  procedure  is  similarly  carried  out  for  as  many  spaces 
as  indicated,  taking  in  two  or  three  spaces  above  and  below  the 
proposed  field,  as  the  lateral  branches  of  these  nerves  freely  overlap. 

It  must  be  remembered  that  the  intercostal  nerves  lie  deep  down 
near  the  pleura,  and  the  injections  must  be  made  well  down  in  the 
intercostal  spaces;  this  is  best  shown  by  a  reference  to  Fig.  67 ;  punc- 
turing the  pleura  should  be  avoided,  but  if  done  no  damage  will  result, 
only  the  solution  is  wasted. 

To  anesthetize  the  anterior  chest  watt  in  front  an  injection  is  made 
subcutaneously  over  the  clavicle  to  block  the  branches  of  the  supra- 
clavicular  nerves  as  they  descend  over  this  bone.  This  is  best  done 
by  making  an  intradermal  station  over  the  middle  of  this  bone,  and 
passing  the  long  needle  subcutaneously  in  both  directions,  injecting 
as  the  needle  is  advanced  until  the  ^entire  area  has  been  infiltrated. 
(See  Fig.  68.) 

A  wall  of  anesthesia  must  then  be  established  from  the  middle  of 
this  bone  outward  to  block  the  branches  of  the  anterior  thoracic 
nerves  as  they  descend  beneath  the  pectoral  muscles;  this  must 
extend  from  the  skin  to  the  chest  wall  through  the  substance  of  the 
pectoral  muscles  through  which  the  nerves  run,  and  outward  as  far 
as  the  axilla.  (See  Fig.  68.) 

These  two  last  injections,  when  combined  with  anesthesia  of  the 
upper  intercostals,  produce  an  area  of  anesthesia  of  the  pectoral 
region  and  underlying  chest  wall  including  the  pleura. 

The  removal  of  a  rib  along  its  entire  course  for  tuberculosis,  os- 
teomyelitis, etc.,  is  fairly  satisfactorily  done  under  local  methods, 
except  for  the  upper  ribs,  which  underlie  the  shoulder  girdle  and  are 
difficult  of  access,  but  any  of  the  lower  ribs  can  be  easily  removed 
from  their  angle  forward  by  blocking  the  intercostal  nerves  for  about 
two  spaces  above  and  below ;  this,  combined  with  a  fairly  free  subcu- 
taneous infiltration  along  the  course  of  the  posterior  thoracic,  where 


THE  THORAX  AND  BACK- 


307 


this  nerve  crosses  the  rib,  will  be  found  to  be  sufficient.  Where  several 
ribs  are  involved  this  procedure  will  be  found  very  satisfactory,  but 
where  only  one  is  involved  through  but  a  part  of  its  course  it  will  be 
found  that  simple  infiltration  is  to  be  preferred.  Starting  at  the 
proximal  end  of  the  field  an  intradermal  station  is  made  over  the 
rib,  and  the  long  needle  entered  at  this  point  and  advanced  in  the 
deep  tissues  close  to  the  rib,  injecting  as  the  needle  is  advanced,  re- 
entering  it  further  on  if  necessary,  until  the  entire  subcutaneous  field 
has  been  injected;  we  then  return  to  the  skin  and  finish  the  injection 


Fig.  70. — i,  Method  of  injecting  field  for  thoracotomy:  i  and  2,  Direction  of  long 
needle  to  intercostal  spaces  above  and  below  rib  to  be  resected;  3,  crescentic  wall  of 
anesthesia  made  subcutaneously  embracing  field;  4,  line  of  incision.  2,  Method  of 
anesthetizing  sternal  region. 

intradermally  along  the  proposed  line  of  incision  over  the  rib.  The 
object  in  making  the  deeper  injections  first  is  to  allow  ample  time 
for  the  solution  to  diffuse  while  making  the  skin  injection  and  thus 
save  the  necessity  of  having  to  wait  later. 

Less  is  known  about  the  sensibility  of  the  parts  within  the  thorax 
than  about  the  contents  of  any  other  cavity  of  the  body,  but  it  is 
believed  that  the  same  general  rules  governing  the  sensibility  of  the 
abdominal  contents  hold  good  here,  that  is,  that  the  parietal  pleura 
is  sensitive  and  the  visceral  insensitive;  the  same  with  the  pericar- 


308  LOCAL  ANESTHESIA 

dium.  The  lung  is  said  to  have  no  sensation.  After  the  chest  walls 
and  parietal  pleura  have  been  anesthetized,  an  exploring  needle  can 
be  passed  freely  within  its  substance  without  complaint,  and  it  can 
also  be  sutured  to  the  chest  wall  without  pain.  The  diaphragm  is 
usually  not  sensitive. 

The  operation  of  thoracotomy  is  quite,  easily  performed  on  almost 
any  part  of  the  thorax  wall.  After  a  consideration  of  the  course  of 
the  nerves,  it  is  seen  that  an  injection  proximal  to  the  field  of  opera- 
tion will  block  all  nerves  entering  the  area.  Suppose  we  were  to  do  a 
thoracotomy  for  empyema  in  the  axillary  line,  with  resection  of  the 
seventh  rib,  a  point  over  this  rib  and  just  behind  the  field  is  selected 
and  an  intradermal  injection  made  with  fine  needle.  The  large 
syringe  and  long  needle  is  now  taken,  and  the  needle  entered  at  this 
anesthetized  point  and  passed  down  to  the  interval  between  the  sixth 
and  seventh  rib,  injecting  lightly  as  it  is  advanced,  until  the  plane  be- 
tween the  intercostal  muscles  is  reached.  This  can  be  fairly  accu- 
rately determined  by  placing  a  finger  firmly  between  the  ribs  and  over 
the  point  of  the  advancing  needle.  It  should  be  remembered  that 
the  nerve  lies  near  the  lower  border  of  the  rib.  When  the  desired 
point  is  reached,  about  i  or  2  drams  of  solution  is  injected.  The 
needle  is  then  slightly  withdrawn  and  passed  in  the  opposite  direction 
in  the  space  between  the  seventh  and  eighth  ribs,  and  a  similar  injec- 
tion made.  While  we  are  waiting  for  the  injection  to  act  here,  the 
infiltration  of  the  skin  is  finished.  This  is  done  rather  freely,  in  a 
crescentic-like  course,  over  the  sixth,  seventh,  and  eighth  ribs,  the 
horns  of  the  crescent  turned  toward  the  operative  area  (Fig.  70). 

The  anesthesia  resulting  from  the  above  injection  in  the  area  just 
in  front  should  be  perfect,  including  the  bone  and  pleura,  and  the 
operation  can  be  commenced  by  the  time  the  skin  infiltration  is 
finished. 

In  the  event  that  the  operative  field  is  slightly  in  front  of  the 
anterior  axillary  line  a  rather  free  subcutaneous  injection  is  made, 
in  addition  to  the  above,  to  meet  the  anterior  divisions  of  the  lateral 
cutaneous  branches  of  the  intercostals  given  off  at  this  point.  If 
preferred,  a  rib  may  be  resected  in  any  part  of  its  course  by  thorough 
infiltration  from  the  skin  to  the  rib  along  the  proposed  line  of  incision 
and  after  the  rib  has  been  exposed  blocking  the  intercostal  spaces 
above  and  below  at  the  proximal  end  of  the  field.  (Fig.  71). 

Transthoracic  hepatotomy  for  abscess  is  quite  satisfactory  under 
local  anesthesia;  the  larger  and  more  superficial  the  abscess  the 
easier  is  the  procedure.  It  should  not,  however,  be  done  without 


THE    THORAX   AND  BACK  309 

first  positively  locating  the  abscess  with  an  exploring  needle,  and 
the  needle  left  in  position  while  the  infiltration  is  being  carried  out. 
This  is  done  the  same  as  for  thoracotomy,  either  by  blocking  the 
nerves  or  by  massive  infiltration.  The  rib  next  below  the  exploring 
needle  is  exposed  and  resected  for  about  2  or  3  inches.  If  it  is  found 
now  that  the  diaphragmatic  pleura  is  adherent  to  the  parietal,  the 
incision  can  be  made  at  once  down  to  the  abscess,  along  the  course  of 
the  exploring  needle  which  has  been  left  in  position.  The  diaphragm 
is  not  usually  sensitive,  but,  if  it  is  found  so,  a  few  small  syringes  of 
solution,  distributed  along  the  course  of  the  proposed  incision,  will 
suffice  to  control  it.  The  liver  itself  is  never  sensitive.  If  it  is 
found  that  the  pleural  space  is  still  open  at  this  point,  the  diaphragm 
must  be  sutured  to  the  chest  wall  before  the  abscess  is  incised.  In 
doing  this,  if  pain  is  occasioned,  the  diaphragm  is  easily  reached 
with  a  long  needle  and  infiltrated.  To  illustrate  the  extensive  pro- 


Fig.  71. — Schematic  representation  of  method  of  anesthetizing  rib  for  resection  in  thor- 

actomy.     (From  Braun.) 

cedures,  which  are  possible  under  local  anesthesia  in  this  region,  we 
quote  the  following  from  a  paper  by  the  author,  which  appeared  in 
the  "Transactions  of  the  Orleans  Parish  Medical  Society  for  1909:" 
"The  next  case  is  rather  unusual,  and  one  of  the  most  interesting 
upon  which  I  have  ever  operated,  and,  owing  to  the  rare  combination 
of  conditions  found,  I  would  like  to  put  it  upon  record  at  this  time: 

"H.,  admitted  to  Ward  9,  had  been  suffering  from  dysentery  for  several  weeks, 
having  frequent  bloody  stools,  in  which  amebae  had  been  found.  Medical  treatment 
checked,  but  did  not  stop,  the  bloody  evacuations.  He  shortly  developed  pain  and 
swelling  over  the  region  of  the  liver;  aspiration  showed  pus,  which  again  showed  the 
amebae.  He  was  prepared  for  operation  and  the  liver  again  aspirated.  No  pus  was 
located,  but  instead  a  large  quantity  of  clear  fluid  was  withdrawn  from  the  pleural  cav- 
ity; as  the  patient  was  very  weak  the  chest  was  not  opened,  as  I  did  not  think  thoraco- 
tomy justified  for  a  serous  accumulation.  He  continued  to  do  badly,  so  on  August  9, 
1009,  under  local  anesthesia,  the  eighth  rib  was  resected  and  a  large  pleural  effusion 
evacuated ;  the  fluid  was  now  of  a  sanguinous  character.  I  felt  this  was  not  sufficient  to 
account  for  the  marked  sepsis  and  effusion,  as  well  as  the  physical  signs  we  had  obtained 


3io 


LOCAL   ANESTHESIA 


on  examination,  so  explored  further,  enlarging  the  opening  in  the  chest  wall  for  inspec- 
tion. The  lung  was  seen  bound  down  to  the  diaphragm  in  the  middle  line,  some  distance 
from  the  chest  wall,  and  looked  and  felt  boggy.  An  aspirating  needle  was  passed  into  it 
a  short  distance  and  withdrew  a  thick,  white  creamy  pus.  A  free  incision  was  then 
made,  opening  an  enormous  pus  cavity,  which  must  have  contained  several  pints,  and 
extended  in  toward  the  median  line  about  8  inches.  The  incision  in  the  lung  caused  no 
pain.  Through  this  opening  in  the  lung  I  explored  the  region  of  the  diaphragm.  At  one 
point  it  felt  distinctly  fluctuating,  and  with  my  finger  I  broke  through  the  diaphragm, 
opening  a  small  pocket  of  pus  of  a  chocolate  color.  It  was  of  small  size  and  at  rather  an 
inaccessible  point,  which  explained  our  missing  it  the  second  time  with  the  aspirator. 
We  thus  had  in  this  case  three  distinct  cavities,  each  yielding  a  different  kind  and  color 
of  pus.  The  openings  into  these  several  cavities  were  all  enlarged  and  made  to  drain 
through  the  common  opening  in  the  chest  wall  by  large-sized  drainage-tubes.  The  oper- 
ation was  entirely  without  pain.  The  different  specimens  of  pus  were  differently  col- 
lected and  examined  and  found  to  contain  an  organism  resembling  the  Shiga  bacillus, 
but  no  amebae.  It  was  possible  he  was  suffering  from  a  double  infection.  The  only 
way  I  can  account  for  this  peculiar  abscess  combination  is  that  the  liver  abscess  ruptured 
into  the  lung,  and  when  relieved  of  its  tension  the  opening  closed.  The  pleural  effusion 
was  a  secondary  phenomena. 

Operations  upon  the  breasts  for  galactocele,  fibromas,  or  other 
benign  growths,  as  well  as  mammary  abscesses,  when  not  too  diffuse, 
can  be  quite  satisfactorily  operated  by  local  anesthesia,  but  for  the 
radical  operation  in  malignant  disease  of  this  gland  a  general  anes- 
thetic should  be  given.  Though  when  necessary  this  can  be  done  by 
local  means  by  first  blocking  the  brachial  plexus  above  the  clavicle, 
the  supraclavicular  nerves  as  they  pass  over  the  clavicle  and  the 
upper  intercostals  behind,  which  procedures  are  amply  discussed. 
(See  Index.) 

For  removal  of  benign  tumors  of  the  breast,  when  well  defined, 
the  skin  infiltration  can  be  begun  on  the  outer  side  at  the  base,  and 
carried  around  the  base  of  the  gland  at  its  attachment  to  the  chest 
wall  on  its  outer  and  under  surfaces  (Fig.  72).  Before  commencing 
the  skin  injection  it  is  well  to  infiltrate  the  tissues  at  the  base  of  the 
gland,  when  the  skin  infiltration  can  be  returned  to  and  finished, 
allowing  the  other  opportunity  to  act,  thus  saving  time.  This  is  done 
in  the  following  manner:  With  a  large  syringe  and  long  needle,  or 
Matas  infiltrator,  the  needle  is  advanced  through  the  anesthetized 
skin  and  directed  into  the  cellular  tissue,  well  under  the  base  of  the 
gland  and  mass  to  be  removed;  while  these  are  held  up  with  one  hand 
to  better  define  this  space,  about  i  ounce  of  the  solution  is  usually 
distributed  here,  but  more  may  be  necessary  if  the  gland  and  mass 
are  large.  After  the  skin  infiltration  has  been  finished,  an  incision 
is  made  at  the  base  of  the  gland,  on  its  undersurface,  at  its  attach- 
ment to  the  chest  wall.  The  gland  is  then  turned  up,  exposing  its 
base,  when  the  removal  of  the  mass  is  accomplished  from  the  under- 


THE   THORAX  AND  BACK 


311 


Fig.  72. — For  operations  upon  the  base  of  the  female  breast,  as  in  the  removal  of 
cysts  and  benign  growths,  a  crescentic  line  of  intradermal  infiltration  is  produced 
around  the  base  and  outer  side  in  the  sulcus  formed  by  the  attachment  of  the  breast 
with  the  chest  wall.  The  breast  is  then  raised,  and  with  the  long  needle  and  large 
syringe  the  cellular  space  beneath  the  breast  is  infiltrated  in  all  directions  with  the 
anesthetic  solution.  The  incision  is  made  in  the  sulcus  and  the  breast  turned  up  and 
operated  upon  from  beneath;  it  is  then  dropped  back  in  place  and  sutured,  leaving 
very  little  scar  visible.  If  the  operative  field  involve  the  upper  part  of  the  breast 
near  its  cutaneous  covering,  this  upper  part  should  be  surrounded  by  subcutaneous 
infiltration  to  block  the  supraclavicular  nerves.  The  nerve-supply  of  the  breast  is 
from  the  intercostals,  which  approach  it  from  the  outer  side  and  beneath,  the  anterior 
thoracic  nerves  from  above  and  externally,  and  the  supraclavicular  nerves  from  above, 
these  latter  supplying  only  the  skin  and  subcutaneous  tissue  as  far  down  as  the  nipple. 


Fig.  73. — Method  of  creating  a  zone  of  anesthesia  around  a  benign  mammary  tumor. 

(From  Braun.) 


312  LOCAL   ANESTHESIA 

surface  and  the  gland  dropped  back  in  place  and  sutured,  the  resulting 
scar  not  being  visible. 

Where  a  simple  growth  or  other  lesion  is  superficially  situated 
on  the  surface  of  the  gland,  a  wall  of  infiltration  anesthesia  is  created 
around  and  beneath  it  in  all  directions  after  the  Hackenbuch  plan 

(Fig-  73)- 

The  method  of  dealing  with  mammary  abscesses  will  depend 
somewhat  upon  their  location;  but,  as  these  usually  point  superfi- 
cially, they  are  best  opened  by  direct  infiltration  over  their  most 
prominent  point. 

THE  STERNUM 

This  is  blocked  by  making  two  vertical  intradermal  lines  of  anes- 
thesia just  to  the  outer  side  of  the  costochondral  junction,  away 
from  the  line  of  the  internal  mammary;  these  lines  should  meet  above 
and  be  made  subcutaneous  here  to  block  the  suprasternal  branches  of 
the  supraclavicular  (see  Fig.  70),  the  long  fine  needle  is  then  used, 
and  intercostal  injections  then  made  on  each  side  in  the  same  manner 
as  already  spoken  of  for  blocking  these  nerves  behind.  This  plan 
gives  complete  anesthesia  of  this  region  and  the  sternum  can  be  re- 
sected if  necessary. 

Where  the  field  of  operation  is  limited  to  a  small  area,  either  of 
the  overlying  soft  parts  or  of  the  chest  wall,  an  area  of  anesthesia 
surrounding  these  parts  is  ample,  as  already  described. 

Operations  on  the  thorax  with  the  above  technic  have  proved  very 
satisfactory,  and  it  is  the  procedure  usually  adopted  by  us,  but  where 
preferred  simple  massive  infiltration  can  be  employed,  either  directly 
in  the  line  of  the  proposed  incision  or  in  a  crescentic  or  circular  man- 
ner, embracing  the  field  and  carried  from  the  skin  to  the  ribs,  without 
regard  to  the  course  of  the  nerves.  This  procedure,  while  satis- 
factory, requires  much  more  of  the  solution,  which  may  be  objec- 
tionable if  the  operative  field  is  very  large. 

THE  BACK 

The  surgical  affections  of  this  region  are  rather  limited,  and  con- 
sist chiefly  of  carbuncles,  furuncles,  superficially  situated  growths, 
such  as  epitheliomas,  moles,  and  the  removal  of  an  occasional  bullet 
from  beneath  the  skin;  the  back  is  also  a  favorite  site  for  lipomas 
and  fibrolipomas,  the  latter  often  attaining  a  large  size  and  usually 
pedunculated. 

Carbuncles,  unless  they  penetrate  too  deeply,  are  quite  satisfac- 


THE    THORAX   AND   BACK  313 

torily  operated  upon  by  local  anesthesia;  the  superficial  extent  of 
the  lesion,  unless  enormous,  is  not  usually  a  centra-indication,  but 
the  depth  to  which  it  extends,  should  it  burrow  down  into  the  deep 
muscles  and  be  situated  over  the  midline  of  the  back,  may  prevent 
our  reaching  the  nerves  at  their  exit  from  the  spinal  canal,  except  by 
going  through  diseased  tissue,  which  is  objectionable;  however,  the 
depth  to  which  lesions  penetrate  is  of  no  consequence  if  sufficiently 
removed  from  the  midline  to  permit  a  long  needle  to  be  passed  down 
through  healthy  tissue  to  reach  the  interval  between  the  ribs. 

In  patients  suffering  from  carbuncles  we  often  have  complicating 
constitutional  conditions,  such  as  diabetes,  nephritis,  or  profound 
sepsis,  which  contra-indicate  the  safe  employment  of  a  general  anes- 
thesia. In  these  conditions  local  methods  should  be  given  the  prefer- 
ence if  it  is  possible  to  employ  them. 

The  nerves  of  the  back  are  divided  into  two  sets  of  branches — 
anterior  and  posterior.  The  anterior  branches  (intercostals)  run 
downward  and  forward,  and  have  been  described.  The  posterior 
branches  run  backward  and  are  distributed  to  the  soft  parts  lying 
on  either  side  of  the  midline. 

To  block  the  nerves  of  the  back,  to  the  side  of  the  midline,  the 
procedure  is  the  same  as  for  operations  upon  the  thorax  by  block- 
ing the  intercostals.  If  the  field  is  high  up  in  the  dorsal  region,  an 
additional  wall  of  anesthesia  will  be  necessary  above  the  field,  and 
should  be  made  well  down  to  the  deep  muscles  to  reach  any  nerves 
descending  from  above. 

If  over  the  midline,  the  procedure,  as  indicated  in  Fig.  75,  may  be 
carried  out  on  the  Hackenbuch  plan  (see  Fig.  19),  which  may  also  be 
used  to  advantage  in  any  region  of  the  back. 

In  the  lumbar  region,  except  close  to  the  spine,  the  exact  point 
of  the  nerve  cannot  be  determined  with  any  degree  of  accuracy ;  it  is 
then  necessary  to  create  a  wall  of  anesthesia  in  the  deep  muscles  to 
meet  the  nerves  as  they  come  through,  having  the  injections  surround 
the  field  on  its  inner  and  upper  parts  to  meet  the  nerves  as  they  run 
downward  and  forward  (Fig.  75),  in  the  thorax  between  the  ribs 
(see  Nerve-supply  of  Thorax) ,  in  the  lumbar  region  between  the  deep 
lumbar  muscles  (Fig.  74).  We  must  remember  that  the  area  of 
distribution  of  any  one  nerve  is  overlapped  by  the  nerves  lying  above 
and  below  it,  and  in  some  occasions,  such  as  the  upper  part  of  the 
thorax,  is  crossed  by  nerves  running  in  a  different  direction. 

By  operating  in  this  way,  procedures  of  considerable  magnitude 
can  be  satisfactorily  and  painlessly  performed,  and  often  with  com- 


LOCAL   ANESTHESIA 

paratively  little  solution,  but  it  is  necessary,  when  making  para- 
neural  injections  in  this  way,  to  allow  a  sufficient  time  to  elapse  (ten 
to  fifteen  minutes)  for  the  anesthesia  to  become  well  established  be- 
fore beginning  the  operation.  If  the  operation  is  near  the  midline 
of  the  back,  a  subcutaneous  wall  of  anesthesia,  made  up  and  down 


the  back  near  the  line,  will  meet  and  block  any  overlapping  branches 
from  the  opposite  side. 

This  method  of  operating  will  be  found  very  satisfactory  in  deal- 
ing with  carbuncles  and  malignant  growths  when  it  is  necessary  that 
the  infiltration  should  not  be  made  into  the  diseased  tissue. 

Where  the  field  of  operation  is  somewhat  removed  from  the  mid- 


THE    THORAX   AND   BACK 


315 


line,  the  depth  of  the  tissues  is  much  lessened  and  the  procedure 
simplified.  It  is  necessary  here  to  create  a  somewhat  crescent- 
shaped  wall  of  anesthesia  on  the  proximal  side  from  the  surface  to 
the  deep  parts,  injecting  between  the  ribs,  and  having  the  horns  of 
the  crescent  to  slightly  embrace  the  field  of  operation,  the  same  as 
has  been  suggested  in  Fig.  75. 


Fig.  75. — i,  Hackenbuch  plan  of  anesthesia  embracing  operative  area:  Circle  of 
cutaneous  anesthesia  first  surrounds  field;  long  needle  enters  at  several  points  on  this 
circle  and  is  directed  obliquely  downward  and  inward  infiltrating  deep  planes.  (See  Fig. 
19.)  2,  Method  of  anesthetizing  operative  field  in  lumbar  region:  Dotted  line — extent 
and  direction  of  cutaneous  anesthesia;  heavy  dots — points  for  inserting  needle  for  deep 
injections  into  muscle  walls;  oblique  lines — area  of  resulting  anesthesia;  cross-lines — 
operative  field. 

By  the  above  procedures,  we  have  often  operated  large  carbuncles 
or  removed  growths  and  have  frequently  resected  ribs,  and  on  one 
occasion  removed  an  entire  rib  for  tuberculous  disease. 

Large  pedunculated  fibrolipomas,  common  to  the  back,  can  be 
very  easily  removed  by  local  anesthesia  by  injecting  a  collar  of  anes- 
thesia in  the  skin  around  the  base  of  the  growth.  After  the  skin 
injection  has  been  started,  a  long  needle  is  passed  deep  into  the  tissues 
at  the  base  of  the  pedicle  and  from  J^  to  i  ounce  or  more  of  Solution 


316  LOCAL   ANESTHESIA 

No.  i  (plus  adrenalin),  according  to  the  size  of  the  growth,  is  dis- 
tributed in  the  tissues  at  the  base.  While  this  is  being  allowed  time 
to  diffuse  we  can  return  to  the  skin  injection  and  complete  this,  when 
the  removal  of  the  mass  can  be  easily  accomplished.  In  this  way 
the  author  has  removed  a  fibrolipoma  about  half  the  size  of  a  water- 
bucket  from  between  the  shoulders  of  an  elderly  gentleman.  Of 
latter  years  the  size  and  unsightly  appearance  of  the  mass  had  kept 
him  indoors,  and  had  almost  anchored  him  to  bed. 


CHAPTER  XVII 
THE  ABDOMEN 

THE  question  of  the  sensibility  of  the  contents  of  this  Pandora's 
box  of  the  human  body,  in  spite  of  the  many  experimental  observa- 
tions on  animals  and  man  and  the  many  daily  operations  performed 
without  general  anesthesia,  still  remains  largely  in  doubt.  At  least 
it  is  a  much  disputed  question  between  the  followers  of  Lennander  on 
the  one  side,  and  those  who  have  arrived  at  their  conclusions  as  the 
result  of  purely  animal  experimentation  on  the  other. 

Of  one  thing  we  are  sure,  there  is  nothing  more  certain  or  real 
than  the  existence  of  intra-abdominal  pain — peritonitis,  appendicitis, 
enteric,  biliary  and  renal  colic,  etc.  Such  are  daily  observations  in 
the  routine  of  the  physician's  work;  still,  we  are  confronted  with  the 
statement,  as  the  result  of  accumulated  surgical  evidence  from  re- 
liable sources,  that  the  intra-abdominal  organs  feel  no  pain,  whether 
normal  or  inflamed. 

While  this  subject  has  been  investigated  by  earlier  writers,  both 
physiologists  and  surgeons,  it  had  not  been  given  the  attention  and 
study  it  merited  until  undertaken  by  the  late  K.  G.  Lennander,  who 
made  a  most  careful  and  thorough  investigation,  publishing  his 
results  in  1901,  and  since  that  date  up  to  the  time  of  his  death.  His 
conclusions  were  briefly  that  the  parietal  peritoneum  is  intensely 
sensitive  to  pain,  but  not  to  pressure,  heat,  or  cold;  this  sensibility  is 
increased  by  inflammation;  the  visceral  peritoneum  and  abdominal 
organs  are  entirely  devoid  of  any  sense  of  pain,  even  when  inflamed, 
and  may  be  cut,  crushed,  torn,  or  burned  without  exciting  pain;  in 
other  words,  that  all  pain  arising  from  disturbances  within  the  ab- 
domen is  caused  by  irritation  through  spread  of  inflammation  to  the 
abdominal  walls  or  pressure  exerted  upon  these  parts  innervated  by 
the  cerebrospinal  system,  and  that  those  parts  supplied  by  the  vagus 
and  sympathetic  system  of  nerves  have  no  afferent  fibers  for  the 
transmission  of  painful  impressions.  While  Lennander's  findings 
for  the  mesentery  were  not  positive,  he  considered  it  also  insensitive 
to  any  irritations  or  manipulations,  except  pulling  upon  it,  which 
naturally  exerted  tension  on  the  posterior  abdominal  wall  and  ex- 
cited pain.  Other  investigators  have  stated  that  the  occasional 

317 


318  LOCAL   ANESTHESIA 

production  of  pain  in  the  mesentery,  as  observed  during  operations 
upon  man,  may  be  due  to  the  presence  of  an  occasional  cerebrospinal 
nerve,  which  may  have  found  its  way  into  these  parts  through  an 
anomalous  distribution.  This  view,  however,  is  not  satisfactory,  for 
if  nerves  are  found  in  any  tissue  it  is  intended  that  they  be  there  and 
they  should  be  present  in  all  cases.  Nothnagel  has  attributed  the 
pain  of  intestinal  colic  to  an  anemia  of  the  intestinal  walls  and  pres- 
sure exerted  upon  the  nerves  of  those  parts  through  the  violent 
muscular  contractions;  Wilms,  on  the  other  hand,  accounts  for  the 
same  pain  by  the  violent  peristalsis  producing  a  stretching  of  the 
mesenteric  attachments.  Lennander,  in  investigating  the  same  sub- 
ject, found  that  he  could  stimulate  a  loop  of  the  human  intestine  to 
such  a  degree  that  it  became  hard  and  anemic,  without  the  produc- 
tion of  pain  until  the  mesentery  was  pulled  upon.  The  last  paper 
from  Lennander's  pen,  which  gives  his  views  on  this  subject,  was  read 
at  the  meeting  of  the  Amer.  Med.  Assoc.,  1907,  and  is  as  follows: 

"From  my  published  works  it  may  be  gathered  that  I  have  not 
been  able  to  find  any  abdominal  organ,  innervated  only  by  the  vagus 
or  the  sympathetic  nerves,  which  is  provided  with  the  sense  of  pain. 
Sensations  of  pain  within  the  abdominal  cavity  are,  according  to  my 
experience,  transmitted  only  by  the  phrenic  nerve,  the  lower  six 
intercostal,  the  lumbar,  and  the  sacral  nerves. 

"My  former  pupil,  M.  Ramstrom,  professor  of  anatomy  at  Upsala, 
has  given  us  the  first  exact  description  of  the  course  of  these  nerves 
within  the  diaphragm  and  the  peritoneal  lining  of  the  anterior  ab- 
dominal wall.  He  has  shown  that  some  of  the  older  descriptions  of 
the  distribution  of  these  nerves  are  incorrect. 

"For  instance,  he  has  not  seen  any  branches  of  the  phrenic  nerve 
running  down  from  the  diaphragm  to  the  anterior  abdominal  wall, 
nor  has  he  been  able  to  trace  a  single  branch  of  the  phrenic  nerve 
through  the  suspensory  ligament  to  the  capsule  of  the  liver.  Simi- 
larly, he  has  been  unable  to  find  any  twigs  from  the  intercostal  nerves 
of  the  diaphragm  which  extend  to  the  capsule  of  the  liver. 

"  These  anatomic  observations  of  Ramstrom  agree  with  my  own 
experience  in  regard  to  the  sensitiveness  of  the  liver.  Even  a  strong 
faradic  or  galvanic  current,  applied  to  the  surface  of  the  liver  above 
the  gall-bladder,  does  not  excite  pain.  In  some  cases,  in  which  the 
position  of  the  liver  was  low,  I  have  separated  the  attached  surface 
of  the  gall-bladder  as  far  as  the  cystic  duct  without  causing  any  pain, 
whereas  the  patient  complained  as  soon  as  I  tilted  the  liver  or  dragged 
on  the  common  bile-duct,  thus  putting  the  cerebrospinal  nerves  of  the 


THE   ABDOMEN  3ig 

abdominal  wall  on  the  stretch.  Not  only  the  sense  of  pain,  but  also 
the  other  modalities  of  sensibility — pressure,  cold,  and  heat — are 
absent  from  the  liver  and  gall-bladder  as  well  as  from  the  stomach 
and  intestines. 

"We  have  often  been  able  to  ascertain  that  viscera  involved  in 
disease  are  quite  as  insensitive  to  operative  measures  and  to  electric 
stimuli  as  are  sound  ones.  Thus,  the  old  theory  defended  by  Flour- 
ens  has  been  destroyed. 

"After  many  investigations — some  of  which  have  been  attended 
by  the  well-known  physiologist,  Hj.  Ohrvall,  and  several  by  Professor 
Ramstrom  as  recorder — we  had  come  to  the  conclusion  that  the 
parietal  peritoneum  of  the  anterior  abdominal  wall  possesses  only  the 
sense  of  pain,  not  the  senses  of  pressure,  cold  and  heat.  (In  most 
cases  it  was  the  peritoneum  behind  the  recti  muscles,  from  a  point 
4  to  5  cm.  above  the  umbilicus  to  a  point  midway  between  the  umbili- 
cus and  the  symphysis  pubis,  which  had  been  examined.)  Should 
this  view  of  OUTS  prove  correct,  it  speaks  decidedly  in  favor  of  the 
specific  character  of  the  nerves  of  pain.  In  other  words,  it  goes  to 
prove  that  the  entire  parietal  peritoneum  is  provided  only  with 
nerves  of  pain — a  condition  previously  known  to  exist  in  the  cornea 
alone. 

"It  is  my  opinion  that  all  painful  sensations  within  the  abdominal 
cavity  are  transmitted  only  by  means  of  the  parietal  peritoneum 
and  its  subserous  layer,  both  of  which  are  richly  supplied  with  cerebro- 
spinal  nerves  around  the  whole  of  the  abdominal  cavity,  possibly  with 
the  exception  of  a  small  area  in  front  of  the  verebral  column  lying 
below  the  crura  of  the  diaphragm  and  between  the  two  chains  of 
sympathetic  nerves.  Here,  as  far  as  I  am  aware,  no  cerebrospinal 
nerves  have  as  yet  been  demonstrated,  and  on  a  few  occasions  I  have 
observed  that  within  this  area  the  patient  does  not  respond  to  hard 
pressure  with  a  finger  or  with  an  instrument;  nor,  furthermore,  does 
he  experience  any  sensation  when  a  small  portion  of  the  mesenteric 
attachment  at  this  point  is  put  on  the  stretch. 

"The  opportunity  is  given  during  operations  of  observing  that 
the  manipulations  which  cause  pain  are  those  which  occasion  stretch- 
ing of  the  parietal  peritoneum  as  well  as  of  the  parietal  attachments 
of  the  mesenteries.  For  example,  pain  is  occasioned  by  the  placing 
or  removal  of  gauze  compresses  between  the  viscera  and  the  parietal 
peritoneum,  by  the  dragging  forward  of  the  cecum,  of  the  vermiform 
appendix,  or  of  any  other  organ  whose  normal  attachment  to  the 
abdominal  wall  is  put  on  the  stretch;  and  the  same  principle  applies 


320  LOCAL   ANESTHESIA 

to  the  stretching  of  any  abdominal  adhesions  which  may  connect  the 
viscera  with  the  abdominal  wall.  On  the  other  hand,  should  a  com- 
press lie  between  the  viscera  without  coming  in  contact  with  the 
abdominal  wall,  the  patient  experiences  no  sensation  when  it  is 
removed.  Similarly,  no  sensation  attends  the  stretching  or  breaking 
up  of  adhesions  which  have  no  connection  with  the  abdominal 
parietes.  As  far  as  I  can  judge  from  my  observations,  the  parietal 
peritoneum  along  the  thoracic  aperture  and  around  the  foramen  of 
Winslow  is  especially  sensitive  to  stretching,  displacement,  etc. 

"A  slow  and  gradual  stretching  of  all  the  layers  of  the  abdominal 
wall  by  ascites  or  meteorism  occasions  distress  rather  than  pain, 
although  a  high  degree  of  meteorism  may  be  attended  by  great  dis- 
comfort. If  in  a  severe  case  of  paresis  of  the  bowel  one  succeeds  in 
emptying  the  intestine  by  means  of  a  typhilitic,  a  jejunal,  or  gastric 
fistula,  the  procedure 'is  followed  by  such  evident  relief  that  the  dis- 
tress of  the  previous  condition  is  emphasized.  That  a  maximum 
degree  of  rapidly  forming  meteorism  is  an  extremely  painful  condi- 
tion, and  one  which  may  rapidly  endanger  life,  I  have  witnesses  in  the 
case  of  a  young  student  who  had  a  coincident  volvulus  of  the  ileum 
and  acute  dilatation  of  the  stomach.  Four  hours  and  a  quarter  after 
the  appearance  of  the  first  symptoms  he  was  pulseless  from  intense 
pain  attended  with  a  sensation  of  bursting. 

"  Infectious  processes  involving  the  abdominal  viscera  (ulcera- 
tions,  acute  inflammations,  etc.)  are  attended  by  lymphangitis  and 
lymphadenitis  of  the  mesenteries.  The  infection  spreads  along  the 
lymph- vessels  to  the  subserous  tissue  of  the  abdominal  wall,  and, 
inasmuch  as  the  lymph-vessels  follow  the  course  of  the  arteries,  the 
lymphangitis  very  soon  reaches  the  sides  of  the  aorta,  along  which  it 
then  may  continue  up  to  the  thoracic  cavity.  A  lymphangitis  of  the 
parietal  subserous  connective  tissue  greatly  increases  the  sensitive- 
ness (excitability)  of  the  cerebrospinal  nerves  to  any  manipulation 
which  occasions  pain  even  under  normal  circumstances. 

"All  that  we  know  of  lymphangitis  and  lymphadenitis  attending 
affections  of  the  mouth,  of  the  pharynx,  of  the  extremities,  etc.,  ap- 
plies equally  well  to  corresponding  processes  within  the  abdominal 
cavity.  We  know,  for  example,  that  the  severity  of  pain  attending 
a  lymphangitis  and  lymphadentis  of  the  above-named  regions  varies 
according  to  different  infections,  and  the  same  thing  is  true  for  the 
abdominal  cavity. 

"The  irritability  of  the  nerves  of  pain  of  the  parietal  peritoneum 
is  much  increased  even  by  the  slight  peritoneal  inflammation.  In 


THE   ABDOMEN  321 

the  case  of  a  serous  peritonitis  (peritonale,  Reizung)  the  boundaries 
of  the  hyperemic  zone  of  the  parietal  serosa  can  be  mapped  out  almost 
to  the  centimeter  by  gentle  palpation  of  the  abdominal  wall.  With 
further  increase  of  the  hyperemia  and  of  the  inflammation  the  sensi- 
tiveness is  at  first  almost  proportionally  increased.  The  fact  that  so 
many  infectious  processes  within  the  abdominal  cavity  begin  with 
diffuse  abdominal  pain  may  be  explained  by  (i)  an  increased  sensi- 
tiveness of  a  large  portion  of  the  parietal  peritoneum,  owing  to  the 
lymphangitis  or  peritonitis;  (2)  a  considerably  increased  irregularity 
of  peristaltic  action  which,  in  addition  to  pain,  often  produces  a  feel- 
ing of  sickness,  vomiting,  and  one  or  more  actions  of  the  bowels  at  the 
commencement  of  these  illnesses.  On  account  of  the  increased  sensi- 
tiveness, the  movements  of  the  stomach  and  intestines  against  the 
parietal  peritoneum  and  the  stretching  of  their  respective  mesenteries 
are  felt  as  severe  pains.  In  most  cases,  however,  the  general  perito- 
neal irritation  soon  passes  off.  Only  the  part  more  especially  infected 
remains  in  a  condition  of  inflammation,  and  the  abdominal  pain  will 
become  localized  at  this  spot.  In  those  cases  where  the  infection 
spreads  over  a  large  portion  of  the  peritoneal  cavity,  thus  giving 
rise  to  a  more  or  less  general  peritonitis,  the  pain  will  diminish  as 
soon  as  the  bowel  becomes  paretic  and  the  nerve-endings  of  the 
parietal  peritoneum  have  been  more  or  less  destroyed  by  the  severe 
inflammation." 

"Pain  in  Connection  with  Perforation. — In  case  of  visceral  per- 
foration or  of  an  abscess  which  ruptures  into  the  free  abdominal 
cavity,  the  primary  pain  is  caused  by  the  contents  of  the  organ,  or  of 
the  abscess,  coming  into  contact  with  the  parietal  peritoneum.  The 
severity  and  character  of  the  pain  depends  on  the  nature  and  quantity 
of  the  escaping  fluid,  the  extent  to  which  it  immediately  comes  into 
contact  with  the  parietal  peritoneum,  and,  lastly,  on  the  intensity  of 
the  contractions  of  the  stomach  and  bowels  brought  on  by  the  irrita- 
tion of  the  peritoneum. 

"Many  clinical  observations  are  explicable  if  one  bears  in  mind 
the  fact  that  only  the  parietal  peritoneum  can  transmit  painful 
sensations.  For  example,  the  primary  pain  occasioned  by  a  duodenal 
perforation  may  be  referred  to  the  iliac  fossa.  Again,  the  paroxysmal 
pains  in  connection  with  a  gastric  ulcer  are  elicited  by  the  movements 
of  the  stomach;  that  is  to  say,  by  its  dragging  on  a  parietal  serous 
membrane  which  is  hyperesthetic  on  account  of  a  lymphangitis 
from  an  infected  ulcer.  If  the  stomach  is  put  at  rest  by  the  aid  of  a 
jejunostomy  the  pains  cease.  Further,  in  the  case  of  a  patient  with 


322  LOCAL  ANESTHESIA 

an  inflammatory  focus,  surrounded  by  small  intestine  and  covered  by 
a  thick  omentum,  pressure  on  the  abdomen  will  disclose  no  tenderness, 
whereas  palpation  per  rectum  may  cause  pain." 

"The  Hypotheses  of  Nothnagel  as  Regards  Colic.- — In  human 
beings  suffering  from  intestinal  fistulae,  and  to  whom  no  anodyne 
has  been  given,  sensation  of  pain  cannot  be  evoked  by  means  of 
chemical,  thermic,  mechanical,  or  electric  stimuli  applied  to  a  portion 
of  the  gut  lying  outside  the  abdominal  cavity  as  long  as  the  stimulus 
or  contractions  which  it  causes  only  affect  the  bowel.  When,  on  the 
other  hand,  the  contracting  bowel  drags  on  adhesions  connecting  it 
with  the  abdominal  wall  it  at  once  produces  pain. 

"Both  theories  of  Nothnagel  are  hereby  disproved,  for  the  colicky 
pain  cannot  be  due  to  pressure  on  the  nerves  of  the  bowel  wall  in 
consequence  of  a  tonic  spasm  of  its  muscular  coat,  since  the  intestinal 
wall  can  be  crushed  with  a  strong  pair  of  forceps  without  eliciting 
any  sensation  whatsoever.  Further,  the  pain  cannot  be  due  to 
anemia  of  the  intestinal  wall  due  to  a  spasm  of  its  muscular  coat, 
since  it  is  possible  by  means  of  electric  stimulus  to  produce  so  power- 
ful a  contraction  of  the  bowel  that  it  becomes  of  tumor  hardness  and 
assumes  a  yellowish-white  color  from  anemia,  without  the  patient 
experiencing  any  sensation,  even  of  being  touched. 

"  Wilms,  in  an  article  and  later  in  his  splendid  work  on  ileus  (1906), 
tried  to  show  that  all  those  pains  which  we  are  accustomed  to  term 
" intestinal  colic"  are  entirely  due  to  stretching  of  the  mesenteric 
attachments.  In  my  first  publication  (1901)  I  made  the  statement 
that  every  distention  or  contraction  of  a  gut  which  is  attended  by  a 
pull  on  its  attachments  to  the  abdominal  wall  is  necessarily  painful, 
as  it  involves  a  stretching  of  the  cerebrospinal  nerves  of  the  parietal 
serous  and  subserous  layers.  With  regard  to  the  duodenum,  the 
duodenojejunal  flexure,  the  three  flexures  of  the  large  intestine,  and 
the  most  distal  part  of  the  ileum,  it  goes  without  saying  that  these 
portions  of  the  bowel  cannot  contract  on  their  contents  in  front  of  an 
obstruction  without  giving  rise  to  a  powerful  dragging  of  their  mesen- 
teries, and  at  the  same  time  a  painful  stretching  of  the  nerves  of  sensi- 
bility of  the  parietal  serosa.  In  similar  fashion,  powerful  intestinal 
contractions  are  bound  to  involve  a  painful  stretching  of  the  parietal 
serosa  in  case  the  bowel  has  become  fixed  to  the  abdominal  wall  by 
adhesions,  and  there  exists  at  the  same  time  some,  obstruction  at  this 
point. 

"The  pains  in  connection  with  ileus,  due  to  kinking,  volvulus,  etc., 
were  thus  easy  to  understand.  On  the  other  hand,  it  was  my  opinion 


THE   ABDOMEN  323 

that  the  stretching  of  a  high  and  free  mesentery  of  the  small  intes- 
tines or  of  the  transverse  colon  could  not  account  for  the  pain  attend- 
ing a  stricture  of  these  parts  of  the  bowel  when  the  stricture  has  not 
become  adherent  to  the  abdominal  wall  or  in  some  way  fixed,  because 
I  could  not  think  that  a  contraction  of  the  bowel  around  its  contents 
in  front  of  the  stricture  could  drag  on  the  parietal  serosa  and  sub- 
serosa  by  that  high  and  free  mesenterium.  Wilms  also  accounts  for 
the  pain  in  these  cases  as  being  only  the  result  of  the  stretching  of  the 
mesentery  proximal  to  the  stricture.  He  considers  that  a  loop  of 
bowel,  contracting  on  its  contents  at  the  proximal  side  of  a  constric- 
tion, endeavors  to  assume  a  straight  form  in  the  same  way  as  does  the 
gut  in  sausage-making.  The  mesentery,  however,  prevents  the 
bowel  from  assuming  the  shape  of  a  straight  cylinder.  The  result 
is  a  stretching  of  the  mesentery,  and  this  is  what  causes  the  pain.  In 
this  connection,  an  observation  was  made  a  year  ago  in  a  case  in 
which  I  had  to  resect  more  than  i  meter  of  the  ileum,  together  with 
the  cecum  and  a  large  portion  of  the  colon,  this  portion  of  the  intes- 
tine having  been  excluded  some  months  previously  by  means  of  an 
ileocolostomy,  on  account  of  multiple  fistulas  and  adhesions  which 
could  not  be  loosened. 

"Under  local  and  a  short  ether  anesthesia  the  excluded  portion  of 
the  bowel  was  completely  freed  from  all  adhesions,  only  the  normal 
mesenteric  attachment  being  left;  the  patient  being  awake,  a  piece 
of  the  ileum,  about  40  cm.  long,  was  clamped  and  inflated  with  air. 
The  bowel  straightened,  the  mesentery  got  stiff  and  assumed  a  fan- 
shaped  form.  While  in  this  position,  standing  out  from  the  vertebral 
column,  the  patient  complained  of  pain,  but  this  passed  off  as  soon 
as  the  bowel  was  emptied  of  air  and  the  mesentery  was  allowed  to 
resume  its  normal  position.  The  experiment  was  repeated  with  a 
considerably  shorter  piece  of  bowel.  The  result  was  the  same,  for  the 
mesentery  again  became  tight  and  stood  out  from  the  vertebral 
column,  occasioning  pain.  Lastly,  a  piece  of  the  intestine,  only  5  or 
6  cm.  long,  was  shut  off.  Although  it  was  inflated  ad  maximum, 
causing  the  serous  membrane  to  burst  and  the  bowel  to  sink  between 
the  two  layers  of  the  mesentery  for  fully  i  cm.,  the  patient  felt  noth- 
ing. As  soon,  however,  as  the  mesentery  was  stretched  for  a  few 
moments  with  the  fingers  pain  was  felt.  These  observations  are  in 
full  accordance  with  the  above-mentioned  view  of  Wilms  as  regards 
the  stretching  of  the  mesentery,  a  view  which  I  believe  to  be 
correct. 

"The  pain  in  connection  with  a  volvulus  of  the  intestine  or  of  an 


324  LOCAL   ANESTHESIA 

ovarian  cyst  naturally  increases  in  proportion  as  the  twisting  comes 
on  quickly  and  more  parietal  peritoneum  is  drawn  into  the  pedicle." 

"Pain  Caused  by  Displacement  of  the  Serous  Membrane  of  the 
Anterior  Wall. — On  many  occasions,  when  performing  a  laparotomy, 
I  have  passed  into  the  abdominal  cavity  a  finger,  covered  with  a  thin, 
smooth  Indian  rubber  glove,  dipped  into  saline  solution,  and  exerted 
a  slight  pressure  on  the  anterior  abdominal  wall.  Of  this  the  patient 
has  no  perception,  but  as  soon  as  the  serous  membrane  is  displaced 
against  the  muscles  or  aponeuroses  of  the  abdominal  wall  the  patient 
has  a  feeling  sometimes  of  touch,  more  often  of  pain,  according  to 
lesser  or  greater  sensitiveness  of  the  individual,  and  according  to  the 
degree  of  pressure  and  displacement  employed.  When  asking  the 
patient,  'Have  you  ever  felt  anything  like  this?'  I  have  usually  re- 
ceived such  answers,  'It  feels  like  colic;'  'It  feels  as  if  the  bowel  is 
being  expanded  by  wind;'  'It's  like  bad  griping  pains;'  'It's  worse 
than  gripes.' 

"Such  sensations  are  occasioned  by  displacing  a  small,  limited 
area  of  the  serous  membrane  at  nearly  any  point  of  the  anterior  ab- 
dominal wall.  On  account  of  these  observations,  I  believe  that  a 
displacement  of  the  serous  lining  takes  place  and  gives  rise  to  pain 
as  soon  as  a  loop  of  intestine  contracts  on  its  contents,  hardens, 
rises,  and  presses  against  the  parietal  peritoneum.  According  to  my 
opinion,  these  pains  occur  not  only  in  connection  with  ileus,  but  also  in 
connection  with  temporary  irregularities  of  the  peristaltic  movement 
of  the  bowels  in  people  not  suffering  from  abdominal  diseases. 
I  have  myself  felt  these  griping  pains,  and  I  have  been  strongly  in- 
clined to  localize  the  same  at  the  anterior  abdominal  wall,  most  often 
to  the  left  lower  quadrant.  As  a  rule,  I  have  attributed  them  to  the 
contractions  of  the  sigmoid  flexure. 

"Here  I  may  mention  a  case  illustrating  the  displacement  of  the 
serous  membrane  of  the  anterior  abdominal  wall  at  the  thoracic  aper- 
ture. It  was  brought  about  by  a  subserous  myoma  of  the  uteri  of 
about  the  size  of  a  mandarin  in  a  woman  eight  or  nine  months  preg- 
nant. She  had  suddenly  been  taken  ill  with  severe  pains,  vomiting, 
and  inability  to  pass  flatus.  A  diagnosis  was  made  by  her  medical 
attendant  of  a  twisted  ovarian  cyst.  As  soon  as  the  myoma  had  been 
removed  under  the  local  anesthesia  all  symptoms  disappeared.  The 
ovaries  were  normal.  The  pregnancy  went  on  to  its  normal  termina- 
tion. I  have  record  of  another  patient,  who  had  a  small  subserous 
myoma  of  the  uterus,  and  in  whom,  after  the  seventh  month  of  preg- 
nancy, abdominal  pains  were  produced  by  any  movement.  They 


THE   ABDOMEN  325 

were  felt  as  a  very  painful  friction,  and  disappeared  as  soon  as  the 
tumor  was  removed. 

"If  the  bowel  wall  on  the  proximal  side  of  an  obstruction  is  con- 
siderably thickened  and  the  serous  coat  rough,  the  '  Darmsteifung' 
is  naturally  attended  by  a  much  more  extensive  displacement  of  the 
parietal  peritoneum  than  in  the  case  of  a  normal  intestinal  wall. 
Contrary  to  Wihns,  I  consider  this  factor  also  to  be  the  cause  of  the 
colicky  pain  which  attends  intestinal  obstruction.  I  have,  conse- 
quently, come  to  the  conclusion  that  'gripes'  are  due  partly  to  a 
stretching  of  the  parietal  attachments  of  the  bowel  and  partly  to  a 
displacement  of  the  serous  lining  of  the  abdominal  wall." 

"Reflex  Rigidity  of  the  Abdominal  Muscles. — The  normal  re- 
sponse of  the  abdominal  muscles  to  an  acute  sensation  of  pain  which 
originates  in  the  parietal  peritoneum  or  subserous  tissue  lies  in  a 
reflex  contraction  (defense  musculaire).  In  case  of  violent  and  very 
extensive  irritation  (hyperemia,  slight  edema)  the  abdomen  assumes 
a  board-like  rigidity  and  the  respiration  becomes  costal  in  type,  for 
the  abdominal  muscles  and  the  diaphragm  are  in  a  state  of  tonic 
contraction.  In  this  way  the  range  of  movement -of  the  abdominal 
organs  is  greatly  diminished,  and  consequently  the  abdominal  pain 
is  greatly  lessened.  Compare  with  this  the  endeavor  of  patients  suf- 
fering from  severe  abdominal  pains  to  get  relief  by  lying  on  the 
'belly/  or  by  fixing  something  tightly  round  the  abdomen.  The  ex- 
tension of  the  reflex  muscular  rigidity  corresponds  closely  to  the  area 
of  peritoneal  irritation  of  the  parietal  serosa.  We  know  little  as  yet 
about  defense  musculaire  in  connection  with  a  mechanical  ileus  be- 
fore the  onset  of  peritonitis.  It  is  necessary  to  observe  with  care 
every  case  of  severe  colicky  pain  attending  an  intestinal  obstruction, 
in  order  to  see  whether  a  tonic  contraction  of  the  abdominal  muscles 
and  diaphragm  takes  place,  with  the  object  of  diminishing  the  move- 
ments of  the  bowels  and  indirectly  the  severity  of  the  pains. 

"In  acute  inflammatory  diseases  of  the  abdomen  I  have  not  ob- 
served the  presence  of  cutaneous  hyperalgesia  so  often  as  one  might 
expect,  especially  in  consideration  of  the  'triade  douloureuse'  of 
Dieulafoy  (i8gg),  which  he  regarded  as  necessary  for  the  diagnosis 
of  an  acute  appendicitis — cutaneous  hyperalgesia,  reflex  muscular 
rigidity,  tenderness  on  pressure.  Before  applying  Head's  theory  of 
cutaneous  hyperalgesia  to  a  given  case,  one  ought  to  consider  the 
question  whether  in  that  special  case  an  infectious  lymphangitis, 
along  the  posterior  abdominal  wall  and  around  the  vertebral  column, 


326  LOCAL  ANESTHESIA 

might  not  cause  a  hyperesthesia  of  the  sensitive  nerve-trunks  and 
spinal  ganglia  of  that  region. 

"It  will,  of  course,  be  clear  to  every  one  that  this  is  only  a  working 
hypothesis.  In  those  few  cases  of  acute  appendicitis  with  cutaneous 
hyperalgesia,  which  have  come  under  my  care  since  I  began  to  pay 
more  attention  to  this  matter,  I  have  observed  co-existing  tender- 
ness on  deep  pressure  in  the  angle  between  the  twelfth  rib  and  the 
erector  spinea  or  somewhat  lower  down  at  the  border  of  this  muscle. 

"When  considering  the  pains  connected  with  infectious  diseases 
of  the  liver  and  gall-bladder,  one  has  to  remember  that  well-known 
embryologic  facts,  as  well  as  my  own  researches  and  the  investiga- 
tions of  Ramstrom,  all  lead  to  the  assumption  that  the  liver,  the  gall- 
bladder, and  the  extrahepatic  bile-passage  do  not  possess  nerves  of 
pain.  One  has  further  to  consider  the  distribution  of  the  lymph- 
vessels  from  these  organs  to  the  posterior  abdominal  wall  and  dia- 
phragm, as  well  as  their  anastomoses  with  the  lymphatics  of  the 
duodenum  and  pancreas.  One  can  then  easily  understand  that  in- 
fectious diseases  of  the  liver  and  gall-bladder  are  apt  to  be  followed 
by  spasms  of  the  diaphragm,  and  that  the  movements  of  the  common 
bile-duct,  the  duodenum,  and  stomach  may  be  attended  by  pain. 
When  the  gall-bladder  contracts  spasmodically  in  order  to  expel  its 
contents  there  results  a  stretching  of  the  cystic  and  common  bile- 
ducts,  and  consequently  a  displacement  of  the  parietal  peritoneum 
and  the  extremely  sensitive  retroperitoneal  connective  tissue  around 
the  common  bile-duct.  If  a  tube  has  been  fixed  (water-tight)  into 
the  gall-bladder  in  a  case  of  cystotomy  for  cholecystitis,  100  c.c.  or 
more  of  saline  solution  may  be  made  to  pass  from  the  gall-bladder 
into  the  duodenum  (the  biliary  passage  being  free)  without  the 
patient  feeling  anything  so  long  as  the  solution  is  being  slowly  in- 
jected into  the  gall-bladder.  If  the  injection  is  made  with  a  little 
greater  force,  the  patient  almost  immediately  complains  of  colicky 
pain  in  the  back. 

"With  a  shrunken  gall-bladder  and  very  wide  common  bile-duct, 
biliary  colic,  due  to  the  stretching  or  distension  of  the  common  bile- 
duct,  is  inconceivable. 

"It  is  quite  necessary  to  consider  carefully  the  account  which  the 
patient  gives  of  his  pain.  Lately  a  patient  of  mine,  suffering  from 
an  acute  hemorrhagic  pancreatitis,  stated  that  the  attack  of  pain 
began  with  a  sensation  as  if  the  large  blood-vessel  at  the  back  had 
burst  near  the  pit  of  the  stomach.  The  autopsy  showed,  in  addition 
to  the  pancreatic  hemorrhages,  a  large  retroperitoneal  extravasation 


THE   ABDOMEN  327 

around  the  celiac  artery  and  the  aorta.  One  must  never  forget  how 
difficult  it  is  to  localize  pain,  and  how  great  an  extent  a  correct  inter- 
pretation of  the  site  of  painful  sensation  is  a  matter  of  practice." 

"Summary. — In  estimating  abdominal  pain,  and  especially  in 
connection  with  illnesses  giving  the  symptoms  of  'ileus,'  we  must 
bear  in  mind,  briefly,  that: 

"i.  Pains  do  not  originate  within  the  abdominal  organs,  which 
are  supplied  only  by  sympathetic  fibers  and  the  vagus  nerves. 

"2.  All  pains  originate  in  the  abdominal  wall,  more  especially 
in  the  parietal  serous  membrane  and  subserous  connective-tissue 
structures  which  are  innervated  by  the  cerebrospinal  nerves. 

"3.  Stretching  of  the  parietal  (mesenteric)  attachments  of  the 
stomach  and  intestines,  as  well  as  of  string-  or  band-like  adhesions 
to  the  abdominal  parietes,  invariably  elicits  pain. 

"4.  The  same  thing  holds  true  for  the  displacement  of  the  parietal 
serosa  from  its  normal  relation  to  the  muscles  or  aponeuroses  of  the 
abdominal  wall. 

"5.  Most  of  the  diseases  connected  with  ileus  are,  at  their  com- 
mencement, attended  by  increased  and,  as  a  rule,  irregular  peristalsis. 

"6.  Chemically  different  substances,  such  as  the  contents  of  the 
stomach,  gall-bladder,  intestine,  or  abscesses,  give  rise  to  severe  pains 
when  they  come  into  contact  with  a  healthy  or  hyperemic  parietal 
peritoneum  (pain  due  to  perforation). 

"7.  Even  that  form  of  acute  peritonitis  which  goes  under  the 
name  of  peritoneal  irritation  (peritoneale,  Reizung)  greatly  increases 
the  sensitiveness  of  the  parietal  serous  membrane. 

"8.  The  sensitiveness  of  the  parietal  peritoneum  at  first  increases 
part  passu  with  the  inflammation,  but  later  decreases  again  when 
the  inflammation  has  reached  a  certain  high  degree,  and  in  many 
cases  may  ultimately  cease  altogether.  (Compare  herewith  erysipe- 
las of  the  skin,  more  especially  the  gangrenous  kind.) 

"I  believe,  finally,  that  we  are  on  the  way  to  completely  under- 
stand the  pains  of  ileus,  though  a  great  amount  of  work  still  remains 
to  be  done.  I  consider  it  to  be  a  very  happy  thought  to  bring  to- 
gether anatomists,  physiologists,  physicians,  and  surgeons  for  the 
discussion  of  this  question,  and  I  feel  not  only  greatly  honored,  but 
also  deeply  grateful,  for  the  invitation  to  contribute  this  introductory 
paper." 

Lennander's  views  have  been  largely  confirmed  and  accepted  by 
many  surgeons  the  world  over,  although  there  still  remain  some 
observations  which  cannot  be  satisfactorily  explained  from  his  stand- 


328  LOCAL   ANESTHESIA 

point.  On  the  other  hand,  the  character  and  standing  of  those  op- 
posing these  views,  and  the  highly  scientific  nature  of  their  experi- 
ments, eliminating  every  possible  avenue  of  chance,  accident,  or 
doubt  in  their  experiments,  almost  forces  conviction. 

The  latest  investigations  in  this  direction  have  been  by  Kast  and 
Meltzer,  at  the  Rockefeller  Institute,  New  York.  In  a  large  number 
of  experiments,  mostly  upon  dogs  (but  also  cats  and  rabbits),  they 
have  proved  in  a  most  convincing  way  that  Lennander's  views  are 
in  error  on  almost  every  point,  at  least  in  so  far  as  they  concern  these 
animals.  They  further  made  the  astounding  revelation  that  the 
amount  of  cocain  used  in  the  infiltrating  solution  for  operations  upon 
animals  (most  previous  observations,  both  on  animals  and  men,  had 
been  made  after  exposing  the  abdominal  contents  under  local  anes- 
thesia) was  sufficient  to  control  through  its  central  action  all  sensa- 
tion of  intra-abdominal  pain.  This  observation  becomes  the  more 
important  and  interesting  when  it  is  remembered  that  the  general 
sensibility  over  the  entire  body  has  been  so  inhibited,  through  the 
central  action  of  cocain,  as  to  permit  the  painless  or  almost  painless 
performance  of  operations.  (See  chapter  on  General  Anesthesia  with 
Cocain.)  Kast  and  Meltzer  also  found  that  through  the  injection 
of  a  moderate  dose  of  cocain  given  in  any  convenient  part  of  the  body 
the  whinnying,  restlessness,  and  excitement  of  the  animal  following 
the  operations  under  general  anesthesia  were  at  once  stopped,  the 
animal  becoming  quiet,  and  to  all  appearances  remaining  in  a  normal 
condition. 

A  thorough  appreciation  of  this  subject  by  the  reader,  as  well  as 
the  difficulties  in  drawing  conclusions  from  the  conflicting  evidence, 
can  best  be  obtained  after  a  review  of  the  facts  presented  by  each 
side.  The  following,  "On  the  Sensibility  of  the  Abdominal  Organs," 
by  Kast  and  Meltzer,  appeared  in  the  "Medical  Record,"  December 
29,  1906. 

The  animals  were  well  narcotized  by  ether,  the  abdomen  opened, 
and  immediately  closed  by  temporary  ligatures  held  together  by 
clamps,  and  when  the  animal  was  partly  out  of  the  anesthesia  one 
or  more  of  the  clamps  were  taken  off,  thus  permitting  one  or  more  of 
the  intestinal  coils  to  come  out.  These,  as  a  rule,  were  kept  moist 
and  covered  with  towels  saturated  in  warm  saline  solution.  In  other 
cases  the  entire  animal  was  kept  in  a  saline  bath  at  39°C.,  the  viscera 
being  well  covered  with  a  warm  saline  solution.  In  still  other  ani- 
mals the  abdomen  was  opened  under  local  (cocain)  anesthesia. 

The  presence  of  sensation  of  pain  was  tested  by  pressing  the  or- 


THE    ABDOMEN  329 

gans  with  the  fingers  or  with  thumb  forceps,  by  touching  them  with 
heated  test- tubes,  and  by  stimulating  with  the  faradic  current,  and 
watching  the  reaction  of  the  animal  to  these  irritations. 

In  all  stimulations  great  care  was  taken  to  avoid  pulling  the 
mesentery  or  touching  the  parietal  peritoneum.  They  write: 

"We  have  tested  the  various  parts  of  the  gastro-intestinal  canal — 
the  spleen,  the  kidneys,  uterus,  bladder,  etc. — but  our  present  state- 
ment refers  essentially  to  the  gastro-intestinal  canal,  which  we  have 
studied  mostly. 

"All  experiments  lead  up  to  one  unmistakable  result,  which  can 
be  stated  in  a  few  words — the  normal  gastro-intestinal  canal  possesses 
the  sensation  of  pain.  But,  besides  the  difference  in  the  subject  of 
observations,  there  was  a  difference  in  the  condition  under  which 
both  observations  were  made.  Lennander  operated  essentially  under 
Schleich's  infiltration  anesthesia.  Schleich's  mixture,  as  Lennander 
employed  it,  consisted  of  5  eg.  of  cocain,  i  eg.  of  morphin,  and  200 
c.c.  of  a  normal  salt  solution. 

"It  seems  advisable  to  us  as  a  further  step  in  our  investigation 
to  study  the  possible  effects  of  these  ingredients  upon  the  sensation 
of  pain  in  the  abdominal  organs. 

"We  began  with  cocain.  The  hitherto  known  effect  of  this  drug 
was  its  local  anesthetic  effect. 

"Lennander  and  other  surgeons  employed  it  for  this  very  quality 
to  deaden  the  pain  during  the  incision,  apparently  without  the  remot- 
est idea  that  the  drug  could  also  effect  the  sensibility  of  the  distant 
isolated  gut. 

"We  nevertheless  decided  to  test  it.  After  establishing  the  un- 
doubted sensitiveness  of  the  intestines,  etc.,  2  eg.  of  cocain  were  in- 
jected into  the  tissues  of  the  abdominal  walls  near  the  incision.  We 
were  then  surprised,  indeed,  when  we  discovered  that  a  short  time 
after  the  injection  all  sensation  disappeared  from  the  intestines. 
Even  a  very  strong  electric  stimulus  no  longer  produced  any  reaction 
or  effect.  After  thirty  or  forty  minutes  the  sensation  returned. 
Such  observations  were  then  repeatedly  made,  and  invariably  with 
the  same  results. 

"Now,  we  could  hardly  think  that  the  cocain  crept  over  by  capil- 
larity or  by  some  other  manner  to  the  intestines,  and  the  observed 
anesthetic  effect  was  a  local  one.  Neither  did  it  seem  probable  that 
the  cocain  crept  along  the  spinal  nerves  to  the  spinal  cord,  and  then 
came  in  contact  with  the  pain-carrying  nerve-fibers  from  the  intes- 
tines. The  most  reasonable  explanation  was  that  the  anesthetic 


330  LOCAL  ANESTHESIA 

effect  was  produced  through  the  circulation.  That  would  mean  that 
cocain  had  not  only  a  local  but  also  a  general  anesthetic  effect.  This 
assumption  was  easily  tested. 

"The  cocain  was  now  injected  in  parts  distant  from  the  abdomi- 
nal cavity,  in  the  thigh,  arms,  pectoral  muscles,  etc.  The  anesthetic 
effect  upon  the  intestines  was  prompt  and  complete  just  the  same. 

"In  further  experiments,  we  have  established  that  i  eg.  was  suffi- 
cient to  bring  about  the  desired  effect,  and  this  even  in  large  dogs 
weighing  14  kilos. 

"We  have,  then,  thus  far  established  two  facts:  that  the  gastro- 
intestinal canal  possesses  the  sensation  of  pain,  and  that  the  subcuta- 
neous or  intramuscular  .injection  of  a  comparatively  small  dose  of 
cocain  is  capable  of  abolishing  this  sensation  for  some  time. 

"We  believe  that  we  are  now  justified  in  offering  the  following 
interpretation  of  the  surgical  observations:  While  we  have  not  the 
slightest  doubt  of  the  correctness  of  the  facts,  namely,  that  when 
operating  under  Schleich's  infiltration  anesthesia  the  abdominal  or- 
gans are  completely  anesthetized,  we  suggest  that  this  anesthesia  is 
due  essentially  to  the  general  effect  of  the  cocain  employed,  and  not 
to  a  normal  absence  of  sensation  in  these  organs. 

"In  the  course  of  the  investigations  we  exposed  some  intestinal 
coils  to  the  drying  effect  of  the  air  in  order  to  bring  on  some  inflam- 
mation, and  we  then  found  that  inflamed  organs  are  distinctly  more 
sensitive  than  normal  ones.  In  fact,  the  sensitiveness  is  often  greater 
than  that  of  the  skin. 

"Now,  Lennander  and  other  surgical  observers  stated  that  in 
their  experiences  also  inflamed  organs  are  completely  anesthetic. 
We  have,  therefore,  tested  the  effect  of  cocain  upon  the  exaggerated 
sensitiveness  of  inflamed  intestines,  and  found  that  a  somewhat  larger 
dose  of  cocain,  say  3  eg.,  will  completely  abolish  all  sensations  also 
from  inflamed  organs. 

"Another  interesting  point  is  the  observation  that  the  parietal 
peritoneum  also  loses  its  sensation  by  a  hypodermic  injection  in  any 
part  of  the  body,  but  the  anesthesia  sets  in  here  later  and  disappears 
earlier  than  in  the  internal  organs. 

"It  is  possible  also  that  the  degree  of  the  anesthesia  is  less,  but 
we  are  not  yet  ready  to  make  any  positive  assertion  on  that  point. 

"An  interesting  and  new  fact  is  the  observation  which  we  made 
on  the  effect  which  the  injection  of  a  small  dose  of  cocain  exerts  upon 
the  psychic  condition  of  the  animal — it  promptly  quiets  excitement. 
The  animals,  which  were  very  restless,  howling  and  crying,  became 


THE    ABDOMEN  331 

perfectly  quiet  one  or  two  minutes  after  an  intramuscular  injection 
of  cocain.  It  may  be  claimed  that  the  quietness  was  due  to  the 
abolition  of  the  pain. 

"We  have  tested  it  on  etherized,  but  not  operated,  dogs.  On 
awakening  from  ether  they  howl  just  as  much  as  operated  animals; 
the  howling  is  not  due  to  pain,  but  to  the  ether  intoxication.  An 
injection  of  cocain  quiets  them  promptly. 

"The  psychic  effect  seems  to  last  longer  than  the  anesthesia  of 
internal  organs.  The  injection  has  no  narcotic  effect;  the  animal  is 
apparently  wide  awake  and  follows  one  with  his  eyes.  The  lid  reflex 
is  not  abolished,  but  the  cornea  is  anesthetic  and  the  pupil  is  widely 
dilated. 

"Whether  the  general  sensibility  is  also  reduced,  that  question 
we  are  not  yet  ready  to  answer." 

Still  more  disquieting  than  the  foregoing  to  the  earlier  accepted 
views  of  Lennander  appears  a  later  paper  by  the  same  careful,  thor- 
ough, and  painstaking  investigators  on  the  sensibility  of  the  abdom- 
inal organs,  which  appeared  in  the  "  Mitteilungen  aus  den  Grenzge- 
bieten  der  Medizin  und  Chirurgie"  for  1909.  As  this  most  interest- 
ing and  instructive  paper  is  a  highly  valuable  contribution  to  this, 
as  well  as  collateral  subjects,  we  hope  the  reader  will  pardon  our 
quoting  from  it  at  length  in  the  author's  own  words: 

"The  surgery  of  our  day  denies  the  sensibility  of  all  the  abdominal 
organs,  notwithstanding  numerous  daily  experiences  to  the  contrary; 
this  question  of  normal  sensibility  belongs  to  the  domain  of  physi- 
ology. But  we  find  here  that  for  a  decade  nobody  has  paid  any  at- 
tention to  the  subject,  and  most  text-books  do  not  mention  a  single 
word  on  the  subject.  But  it  was  not  always  thus — in  the  first  half 
of  the  last  century  many  prominent  physiologists  had  contributed 
to  the  solution  of  this  question.  The  sympathetic  ganglions  and  the 
nerves  distributed  from  them  were  studied  in  the  range  of  the  exam- 
inations. The  results  were  far  from  satisfactory  and  full  of  contra- 
diction. Many  observers  asserted  in  a  positive  manner  that  no  kind 
of  irritation  of  the  sympathetic  ganglions,  their  nerve-fibers,  or  the 
intestines  was  capable  of  producing  pain.  Other  authors,  on  the 
contrary,  equally  well  known  in  the  history  of  physiology,  asserted 
that  strong  irritation  of  these  parts  was  followed  by  severe  pain. 

"Megendie  stated  that  cutting,  tearing,  etc.,  of  the  ganglions 
made  no  impression  upon  the  animal. 

"Bichat  has  also  reported  that  a  dog  had  eaten  its  own  exposed 
intestines,  and  many  other  well-known  authors  have  reported  similar 


332  LOCAL   ANESTHESIA 

observations.  Bichat  further  reported  irritating  the  celiac  plexus 
and  intestines  of  a  dog  by  cutting  or  with  acid  without  producing 
pain.  Johannes  Miiller,  on  the  other  hand,  states  that  mechanical 
and  chemical  irritation  of  the  celiac  plexus  or  the  connective  tissue 
of  the  renal  vessels  in  the  guinea-pig  undoubtedly  caused  pain.  Simi- 
lar observations  were  made  by  Budge,  Gianuzzi,  and  others.  Again, 
other  investigators,  among  them  such  brilliant  names  as  Flourens, 
Longet,  Brachet,  and  Valentine,  take  a  middle  ground.  Some  stated 
that  only  very  strong  or  long-continued  irritation  caused  pain,  and 
then  of  a  mild  degree.  Others  had  pointed  out  that  immediately 
after  the  exposure  of  the  ganglion,  by  no  kinds  of  stimuli  could  pain 
be  produced,  but  that,  on  the  contrary,  after  longer  exposure,  when  it 
had  become  red  or  'otherwise  irritated,'  the  same  stimuli  were  fol- 
lowed by  manifestations  of  pain. 

"Since  the  middle  of  the  last  century,  since  which  time  practical 
surgery  as  well  as  physiologic  experiments  have  made  use  of  general 
anesthesia,  we  scarcely  meet  a  report  on  investigation  which  deals 
with  our  subject.  They  deal  principally  in  consideration  of  other 
problems  in  relation  to  the  sympathetic  nervous  system  of  the  ab- 
domen, in  which  occasionally  observations  are  mentioned  which 
show  that  even  in  narcosis  the  cutting,  crushing,  or  tearing  out  of 
the  splanchnic  nerves  or  the  celiac  ganglion  always  cause  pain 
(Haffter,  Nasse,  Braam-Heuckgeest,  etc.). 

"In  numerous  examinations,  undertaken  without  regard  to  sen- 
sibility, afferent  nerve-fibers  of  the  sympathetic  were  demonstrated 
which  serve  many  reflex  purposes,  as  vasomotor,  cardiac  inhibition, 
respiratory,  etc.  In  relation  to  the  sensibility  to  pain  of  the  abdomi- 
nal organs  we  find  the  physiologic  literature  of  the  last  decades,  as 
far  as  we  are  acquainted  with  it,  to  contain  not  even  occasional  ob- 
servations. Some  authors,  as  Buch,  Richet,  etc.,  who  have  con- 
cerned themselves  with  our  problems,  admit  that  these  organs  nor- 
mally possess  no  sensibility,  but  that  these  organs  can  become  the 
seat  of  intense  pain  when  inflamed  or  otherwise  in  a  condition  of  ab- 
normal irritability. 

"In  recent  times  the  study  of  the  sensation  of  the  abdominal 
organs  has  been  undertaken  by  surgeons.  An  occasional  clinical 
statement  regarding  the  lack  of  sensibility  of  the  abdominal  contents 
is  met  in  the  older  literature  here  and  there. 

"Such  observations  were:  the  apparent  lack  of  sensibility  of  the 
contents  of  herniae  to  mechanical  or  electric  irritation;  or  of  loops  of 


THE   ABDOMEN  333 

the  bowel  fixed  outside  the  abdominal  wall  for  the  purpose  of  creating 
an  artificial  anus;  also  of  prolapsed  portions  of  intestines. 

"  Since  the  introduction  of  local  anesthesia  and  Schleich's  infiltra- 
tion method  numerous  extensive  abdominal  operations  have  been 
undertaken  without  general  anesthesia;  these  offered  apparently  a 
very  favorable  opportunity  for  the  study  of  our  problems.  In  fact, 
many  surgeons  have  made  the  occasional  observations  that  the  ab- 
dominal contents  appear  devoid  of  any  sensation. 

"Bier  has  stated  that  the  intestines  can  be  cut,  squeezed,  burned, 
etc.,  without  producing  pain,  but  in  a  later  contribution  he  adds 
that  tearing  the  intestines  or  the  connective  tissue  of  the  mesentery 
or  separating  adhesions  will  occasion  pain. 

"The  question  was  gone  into  systematically  and  studied  with 
greater  care  by  K.  G.  Lennander.  The  results  of  his  investigations 
are  that  the  intestine,  stomach,  omentum,  mesentery,  spleen,  liver, 
gall-bladder  and  bile-passages,  etc.,  in  short,  all  organs  which  re- 
ceive their  nerve-supply  exclusively  from  the  sympathetic,  possess 
neither  pain  nor  tactile  or  thermic  sensations;  and  this  applies  not 
only  to  the  normal  condition,  but  to  the  inflamed  state  as  well. 

"These  organs,  asserts  Lennander,  possess  simply  no  fibers  for 
the  transmission  of  touch,  temperature,  or  pain.  Only  the  parietal 
peritoneum  feels  pain,  and  this  because  it  is  supplied  with  spinal 
nerves.  Inflammation  increases  the  irritability  of  the  nerves  in  gen- 
eral, and  increases,  therefore,  the  sensibility  of  those  in  the  parietal 
peritoneum.  Lennander  refers  the  origin  of  the  different  kinds  of 
pain  which  occur  in  the  abdomen  to  the  parietal  peritoneum  and  to 
the  spinal  nerves  in  general. 

"Therefore,  would  a  distention  of  the  intestines  and  intensive 
peristalsis  produce  pressure  and  rubbing  upon  the  parietal  perito- 
neum, or  by  producing  a  stretching  of  the  mesentery  which  is  felt 
on  the  spinal  nerves  or  the  root  of  the  mesentery? 

"In  consequence  of  the  inflammation  of  the  abdominal  organs 
there  occurs,  as  Lennander  also  assumes,  not  only  an  increased  irri- 
tability of  the  spinal  nerves,  but  also  the  production  of  lymphangitis, 
which  later  extends  to  the  tissues  which  are  richly  provided  with 
spinal  nerves. 

"Infectious,  toxic,  or  chemically  irritating  materials,  therefore, 
occasion  pain;  they  are  absorbed  through  the  lymph- vessels,  and  are 
immediately  transported  to  parts  supplied  by  the  afferent  spinal 
nerves. 

" Lennander 's  views  are  at  present  shared  by  many  prominent 


334  LOCAL   ANESTHESIA 

surgeons,  among  others  von  Wilms,  who,  on  the  contrary,  sees  in 
the  stretching  of  the  mesentery  the  essential  factor  in  the  production 
of  abdominal  pains. 

"The  most  essential  and  most  striking  feature  in  Lennander's 
views  are  that  the  abdominal  organs,  which  receive  their  nerve-supply 
exclusively  from  the  sympathetic,  are  entirely  incapable  of  feeling 
the  sensations  of  pain,  pressure,  heat,  or  cold. 

"This  view  has  recently  obtained  physiologic  sanction,  and  has 
been  completely  accepted  by  Thunberg  in  the  chapter  on  Tac- 
tile Temperature  and  Painful  Sensation  in  Nagel's  'Handbook  of 
Physiology.' 

"Some  time  ago  we  began  a  series  of  experiments  on  animals  to 
determine  the  sensation  of  pain  in  the  abdominal  organs.  Our  ob- 
servations led  us  to  the  following  conclusion :  The  abdominal  organs 
are  capable  of  painful  sensation  in  the  normal  condition  as  well  as 
in  the  presence  of  inflammation.  At  the  same  time  we  made  the  ob- 
servation that  this  pain  disappears  after  an  injection  of  cocain  given 
in  any  convenient  part  of  the  body. 

"Conclusions. — The  abdominal  organs  of  the  dog,  examined 
through  a  small  opening  in  the  otherwise  closed  abdominal  cavity, 
are  undoubtedly  sensitive  to  pain,  and  are  also  sensitive  outside  of 
the  cavity,  if  only  a  small  loop  is  brought  out  and  tested  immediately 
after  its  exposure.  Inflammation  undoubtedly  increases  the  sensi- 
tiveness of  the  abdominal  organs  of  the  dog.  If  all  the  intestines  or 
a  greater  part  are  eventrated  or  otherwise  freely  exposed,  there  ap- 
pears a  more  or  less  marked  depression  of  the  sensibility,  which  is 
more  complete  the  weaker  the  animal  is;  at  the  same  time  the  animal 
becomes  more  or  less  markedly  apathetic  with  lessening  of  the  cu- 
taneous sensibility.  Laparotomy  also  depresses  the  motor  activity 
of  the  gastro-intestinal  canal.  This  motor  and  sensory  depression 
is  a  reflex  inhibition  of  central  nature,  and  can  also  extend  to  other 
centers. 

"In  weak  animals  and  in  prolonged  procedures  this  inhibition 
may  extend  to  the  vital  centers  in  the  medulla  oblongata,  and  may 
often  lead  to  fatal  shock. 

"It  also  appears  that  the  peripheral  mechanism  in  the  intestinal 
canal  may  also  be  inhibited  to  a  certain  degree.  It  is  evident,  also, 
that  the  intestines  of  cats  and  rabbits  possess  sensory  nerves,  but 
they  are  easily  exhausted  and  are  very  early  and  strongly  influenced 
by  laparotomy;  the  intestines  are  affected  much  quicker  and  more 
profoundly  than  the  mesentery.  The  surgical  experience  on  the 


THE   ABDOMEN  335 

human  subject  does  not  at  all  prove  that  the  intestines  normally  in 
the  normal  closed  abdomen  possess  no  pain-conducting  fibers.  Until 
exact  proofs  are  brought  forward  that  the  sensory  innervation  of  the 
human  abdominal  organs  differs  radically  from  that  of  other  animals 
it  will  have  to  be  assumed  that  as  with  animals,  so  also  with  man, 
the  abdominal  organs  are  provided  with  special  nerve-fibers,  and 
that  the  sensation  of  these  organs  can  be  increased  by  inflammation 
as  we  see  it  in  animals. 

"This  theory  explains  in  a  simple  way  the  well-known  occurrence 
of  all  kinds  of  violent  pain  in  the  human  abdomen." 

After  reading  the  preceding,  one  is  almost  forced  to  conviction 
of  these  views  were  it  not  for  the  daily  repeated  observations  at  the 
operating-table  upon  the  human  subject,  when  it  becomes  self-evi- 
dent that  they  cannot  be  unreservedly  accepted  for  the  human  body 
without  further  observations,  and  we  realize  that  on  this  perplexing 
subject  the  last  word  has  not  yet  been  spoken. 

It  is  very  probable  that  in  the  highly  organized  human  body  con- 
ditions of  sensibility  differ  from  those  found  to  exist  in  the  animal  in 
accordance  with  the  well-known  law  that  the  higher  we  ascend  in 
the  animal  scale  the  more  highly  organized,  complex,  and  sensitive 
becomes  the  nervous  system.  The  fact  that  moderate  doses  of  co- 
cain,  i  to  3  eg.,  is  sufficient  to  abolish  all  intra-abdominal  sensation 
in  dogs,  and  that  large  doses  are  capable  of  producing  general  anes- 
thesia in  man,  must  be  taken  into  consideration  in  arriving  at  any 
conclusions  regarding  intra-abdominal  sensations  during  operations 
upon  man  under  local  anesthesia,  where  it  is  also  possible  that  the 
acuteness  of  the  sensibility  of  these  parts  may  be  somewhat  lessened; 
also  the  fact,  demonstrated  by  Kast  and  Meltzer,  that  free  exposure 
of  the  abdominal  contents  inhibits  or  completely  abolishes  all  local 
as  well  as  general  sensibility;  the  fact  that  such  exposure  if  prolonged 
leads  to  shock  has  been  recognized  in  man,  but  observations  on  the 
sensibility,  either  local  or  general,  long  before  shock  appeared  had 
not  been  reported;  it  is,  however,  well  known  that  during  shock  all 
painful  sensations  are  either  greatly  lessened  or  entirely  abolished. 
The  "apathetic  state"  reported  by  Kast  and  Meltzer,  even  without 
any  fall  of  blood-pressure,  must  be  recognized  as  a  condition  which 
immediately  precedes  shock,  as  indicated  by  the  blood-pressure. 

The  question  of  the  lessened  intra-abdominal  sensibility  through 
the  use  of  cocain  or  its  substitutes,  and  the  depression  of  sensibility 
through  exposure  of  the  abdominal  organs  in  man,  must  now  remain 


336  LOCAL   ANESTHESIA 

an  open  question  until  proved  by  further  observation  on  the  human 
subject  made  with  this  end  in  view. 

In  considering  some  of  the  above  questions  in  the  light  of  infor- 
mation already  obtained  from  operations  performed  on  man,  it  has 
been  proved  that  the  existence  of  adhesions  between  movable  intes- 
tinal coils  does  not  excite  apin  as  a  symptom;  other  disturbances 
may  arise,  but  when  adhesions  have  existed  between  the  intestine 
and  the  abdominal  wall,  pain  has  always  been  experienced.  In  op- 
erating upon  such  cases  under  local  anesthesia,  the  separation  of  the 
adhesions  between  the  several  loops  of  intestines,  no  noteworthy 
complaint  is  made  by  the  patient  provided  the  mesentery  is  not 
pulled  upon,  but  in  separating  adhesion  between  the  intestines  and 
the  abdominal  wall  pain  is  always  felt. 

If  a  finger  is  introduced  into  the  abdominal  cavity  and  firm  pres- 
sure made  against  the  parietal  peritoneum  no  pain  is  produced,  as 
the  parietal  peritoneum  is  insensitive  to  pressure,  but  by  sliding  the 
finger  about  over  the  surface,  traction  is  made  on  the  delicate  and 
sensitive  subperitoneal  tissue  and  pain  produced.  In  this  way  Len- 
nander  believes  that  the  pain  of  some  forms  of  colic  not  explained  by 
pulling  on  the  mesentery  may  be  accounted  for.  The  gradual  and 
general  distension  occurring  in  ascites,  large  tumors,  pregnancy,  etc., 
may  not  cause  pain,  but  the  unequal  distention  and  violent  peristalsis 
of  a  small  loop  may,  by  a  sliding  motion  on  the  parietal  peritoneum, 
excite  acute  pain. 

The  withdrawal  of  packs  and  drainage-tubes  from  between  coils 
of  intestines  excites  very  little  pain,  provided  the  mesentery  is  not 
pulled  on,  in  comparison  to  the  pain  produced  by  removing  them 
when  in  contact  with  the  abdominal  wall.  In  operations  under  local 
anesthesia  the  careful,  gentle  application  of  packs  around  the  field 
and  in  contact  with  the  parietal  peritoneum  does  not  excite  any  com- 
plaint, but  when  being  removed  if  they  are  roughly  dragged  out  the 
patient  will  always  give  unmistakable  evidence  of  decided  pain. 

Investigations  under  similar  conditions  to  those  employed  by 
Kast  and  Meltzer  have  been  undertaken  by  Miiller,  but  he  did  not 
obtain  the  same  results ;  also  by  Hotz,  but  here  the  observations  were 
made  under  morphin  narcosis,  and  are,  consequently,  not  of  the  same 
value;  however,  he  states  that  irritations  of  violent  kinds,  even  in  in- 
flamed conditions,  do  not  excite  pain  unless  the  mesentery  is  pulled 
upon. 

Ritter,  on  the  other  hand,  tried  similar  experiments,  and  was  able 
to  completely  confirm  Kast's  and  Meltzer's  findings  and  oppose  those 


THE   ABDOMEN  337 

of  Lennander.  In  1909  he  brought  forth  an  entirely  new  theory. 
He  believes  that  the  sympathetic  nerves  are  capable  of  the  transmis- 
sion of  painful  impressions,  but  associates  such  sensation  directly 
with  the  blood-supply,  and  found  that  the  more  vascular  parts  were 
the  more  sensitive,  the  non- vascular,  less  so;  the  vessels  themselves 
are  most  sensitive,  and  in  every  instance  were  painful  when  ligated. 
He  thinks  that  this  means  of  testing  the  sensibility  of  these  parts  is 
the  only  one  that  eliminates  all  possibility  of  error.  Pulling  upon  the 
mesentery  was  eliminated  by  a  series  of  double  ligatures;  in  placing 
these,  if  the  proximal  was  tied  first  it  alone  caused  pain,  the  applica- 
tion of  the  distal  one  being  painless;  but  if  the  distal  one  was  tied 
first,  then  both  caused  pain.  He  found  that  cocain  injected  around 
the  blood-vessels  renders  anesthetic  the  viscera  supplied  by  them, 
and  thinks  that  injury  to  the  vessels  is  important  in  the  production 
of  shock,  and  advises  that  when  working  under  local  anesthesia  all 
vessels  of  any  size  should  be  cocainized  before  ligation  and  division. 

He  does  not  think  that  the  cocain  used  in  performing  laparot- 
omy  has  had  so  much  to  do  with  the  negative  findings  of  many  sur- 
geons as  the  inhibition  of  sensation  brought  about  by  the  exposure 
of  the  delicate  nerve-fibers  in  the  abdominal  cavity. 

These  later  findings  by  Ritter  have  attracted  the  favorable  at- 
tention of  some  observers;  further  investigations  may  prove  their 
value,  but  we  must  bear  in  mind  two  points:  first,  that  cutting  off 
the  blood-supply  always  lessens  the  sensibility  of  the  parts;  second, 
that  the  sympathetic  nerves  (if  they  have  been  proved  to  contain 
pain-conducting  fibers)  are  largely  distributed  upon  the  blood-vessels, 
and  the  ligation  of  these  vessels  may  completely  block  their  power  of 
conduction. 

In  another  publication  Ritter  has  stated  that  the  free  exposure 
of  the  intestines  in  non-anesthetized  patients,  as  well  as  pinching 
them  with  forceps,  causes  pain.  Mitchell  reports  2  cases  and  Haim 
i  case  operated  without  narcosis  and  without  cocain,  and  they  state 
that  the  lack  of  sensibility  of  the  intestines  was  similar  to  that  ob- 
served in  similar  operations  under  cocain.  Two  of  these  cases  had 
carcinoma  of  the  stomach  and  the  third  an  irreducible  hernia.  While 
these  examinations  were  more  to  the  point,  the  cases  must  have  been 
very  ill  to  have  been  operated  without  any  form  of  anesthesia,  and 
this  condition  must  have  had  some  effect  in  shocking  or  inhibiting  the 
sensibility;  however,  the  number  is  too  small  from  which  to  draw  any 
definite  conclusions.  Nystroem,  a  former  assistant  of  Lennander,  in 
a  recent  paper  champions  the  theories  of  his  former  chief,  and  ques- 


338  LOCAL   ANESTHESIA 

tions  the  value  of  experimentation  upon  animals  in  settling  these 
points,  and  calls  attention  to  the  widely  different  results  obtained  by 
different  investigators  in  the  same  experiment.  He  tried  the  same 
experiments  carried  on  by  Kast  and  Meltzer,  and  obtained  exactly 
opposite  results,  and  could  excite  no  pain  unless  the  mesentery  was 
pulled  upon  or  the  parietal  peritoneum  irritated.  He  then  experi- 
mented upon  a  case  of  hernia  in  a  man :  the  abdomen  was  first  opened 
by  a  small  incision  under  ether  narcosis,  the  peritoneum  was  then 
temporarily  closed,  and  the  patient  allowed  to  recover.  The  parietal 
peritoneum  was  then  tested  and  found  very  sensitive,  but  the  irrita- 
tion of  a  loop  of  intestine  which  was  found  present  at  the  opening 
gave  no  evidence  of  sensation  until  the  mesentery  was  pulled  upon. 
From  these  and  other  observations  Nystroem  concludes  that  the  con- 
tradiction of  Lennander's  work  is  not  to  be  unhesitatingly  accepted. 
While  he  admits  the  existence  of  many  points  which  cannot  be  satis- 
factorily explained  by  these  views  at  present,  it  is  wise  to  withhold 
judgment  until  further  observations  can  be  made. 

Kast  and  Meltzer,  in  discussing  the  opposing  views  given  by  some 
of  the  above-mentioned  investigators,  state  the  following: 

"Now  we  will  try  to  solve  the  question  on  the  ground  of  our  ex- 
perimental experiences.  In  dogs  we  have  almost,  without  excep- 
tion, confirmed  the  sensibility  of  the  abdominal  organs;  we  have 
found  that  by  the  free  exposure  of  the  intestines  their  sensibility  is 
reduced  and  that  this  reduction  is  more  pronounced  the  weaker  the 
operated  animal.  We  have  further  found  that  in  cats  and  rabbits 
the  abdominal  contents  are  sensitive,  but  that  in  these  animals  the 
opening  of  the  abdomen  exercises  a  much  stronger  influence  upon  the 
sensibility  than  with  dogs,  and  that  often  a  single  exposure  and  irrita- 
tion suffice  to  suspend  reaction.  The  sensibility  of  the  intestines 
is  yet  more  fleeting  than  that  of  the  mesentery,  and  with  rabbits  more 
fleeting  than  with  cats.  How  does  it  stand  now  with  the  sensibility 
of  the  abdominal  organs  of  man?  Here  we  have  essentially  the  prin- 
cipal question  in  view :  Do  the  abdominal  organs  of  man  possess  pain- 
conducting  fibers? 

"This  has  been  positively  denied  by  competent  surgeons.  If  one, 
however,  considers  how  such  a  denial  involves  theoretically  and 
practically  very  important  assumptions,  and  if  one  considers  still 
further  how  such  an  assumption  must  now  appear  even  more  import- 
ant, since  it  establishes  a  radical  difference  in  the  innervation  between 
man  and  other  mammals,  it.  is,  therefore,  clear  that  such  a  state- 
ment can  only  be  accepted  when  based  on  exact  proofs.  But  are 


THE   ABDOMEN  339 

there  such  exact  proofs?  We  have  first  the  large  number  of  observa- 
tions which  have  been  made  under  cocain  anesthesia,  but  we  have 
proved  that  a  cocain  injection,  even  without  touching  the  intestine, 
is  able  to  temporarily  abolish  this  sensibility.  The  surgeons  who 
have  not  sufficiently  investigated  it  doubt  this  statement.  But  it  is 
a  certain  fact,  and  it  has  also,  as  above  mentioned,  been  recently 
confirmed  by  Ritter.  Here  one  must  consider  that  to  reply  to  our 
question  in  the  affirmative  it  is  not  at  all  necessary  to  assume  that 
the  sensibility  must  be  intense. 

"It  may  appear  in  man  after  opening  the  abdomen  as  weak  as  we 
have  found  it  in  cats  and  rabbits,  and  the  small  doses  of  cocain  which 
are  ordinarily  used  may,  therefore,  completely  suffice  to  suspend  this 
slight  sensibility.  Also  the  surgical  observations  which  have  been 
made  with  the  use  of  cocain  are  absolutely  not  such  convincing  proofs. 
May  the  few  recent  observations  which  have  been  made  without  the 
use  of  cocain  in  these  cases  be  accepted  as  such  positive  proof? 
Certainly  not.  Again,  have  we  seen  that  other  observations  speak 
for  the  contrary  that  the  human  intestines  have  painful  sensations. 
We  must  further  mention  that  the  above-cited  three  negative  obser- 
vations were  made  upon  very  sick  patients,  and  here  we  must  remem- 
ber our  experimental  experiences  that  the  weaker  the  animal  the  more 
profoundly  was  the  sensibility  reduced  by  laparotomy ;  and  yet,  again, 
may  we  add  that  as  regards  the  sensibility  of  the  abdominal  organs 
of  man  after  laparotomy  they  may  behave  as  in  cats  and  rabbits. 

"To  recapitulate,  the  observations  which  were  made  under  the 
use  of  cocain  are  on  account  of  the  cocain  not  of  proportionate  value. 
The  observations  which  were  made  without  cocain  are  quite  small  in 
number,  are  not  without  contradiction,  and  were  made  on  very  weak 
patients.  Moreover,  laparotomy  depresses  the  sensibility  consider- 
ably, and  in  quite  weakened  animals,  also  in  several  kinds  of  animals 
in  rather  normal  condition,  was  the  sensibility  completely  suspended. 
The  surgical  observations  contain,  therefore,  not  only  no  kind  of  posi- 
tive proof,  but  contain  in  general  no  proof  at  all  that  the  abdominal 
organs  of  the  normal  man  in  the  normal  closed  abdomen  are  unable 
to  feel  painful  sensations. 

"As  we  have  no  proof  to  offer,  we  are  justified  in  accepting  that 
the  visceral  innervation  of  normal  man  in  the  normal  closed  abdo- 
men does  not  differ  essentially  from  that  of  other  mammals,  and  that 
the  abdominal  organs  are  more  or  less  richly  provided  with  pain- 
conducting  nerve-fibers.  We  are  further  justified  in  accepting  that 


340  LOCAL  ANESTHESIA 

as  with  animals,  so  also  with  man,  a  marked  inflammation  strongly 
increases  the  sensibility. 

"Based  on  the  above  assumptions,  the  most  widely  different  in- 
tense pain  that  the  human  in  his  normal  closed  abdomen  often  has  to 
bear  find  their  simple  explanation,  and  do  not  need  any  interpretation 
by  forced  hypothesis." 

Much  more  might  be  said  pro  and  con  by  each  side  in  the  contro- 
versy, but,  as  our  patients  are  human  and  not  dumb  animals,  clinical 
experience  is  the  most  valuable  and  the  patient  must  be  the  judge 
in  all  cases  and  interpret  his  own  sensation.  While  animal  experi- 
mentation is  undoubtedly  of  tremendous  value  in  furnishing  infor- 
mation and  in  settling  mooted  and  doubtful  points  on  many  subjects, 
it  must  necessarily  always  furnish  very  questionable  data  on  such 
subjects  as  pain,  for  the  dumb  animals  may  either  suffer  patiently 
or  wiggle,  strain,  whine  or  cry  out  as  an  evidence  of  their  displeasure 
at  their  restraint  in  much  the  same  way  they  would  be  expected  to  do 
when  in  pain  and  these  actions  are  more  likely  to  occur  when  we  are 
working  over  them.  The  rise  of  blood-pressure  which  is  always 
associated  with  pain  cannot  always  be  interpreted  this  way  in  animals, 
as  fear  will  produce  the  same  rise,  and  similarly  the  reaction  which 
invariably  takes  place  with  a  fall  of  blood-pressure  when  either  fear 
or  pain  are  prolonged  is  again  a  doubtful  guide,  as  a  very  decided  fall 
of  blood-pressure  occurs  in  shock  which  we  know  from  clinical  ex- 
perience may  be  accompanied  by  little  or  no  pain.  In  my  own  ex- 
perience with  animals,  which  has  been  considerable,  I  am  forced  to 
the  conclusion  that  it  is  a  very  difficult  matter  to  correctly  interpret 
their  sensations. 

Reports  of  animals  under  experimentation  eating  their  own  ex- 
posed intestines  cannot  be  accepted  as  an  argument  by  either  side, 
as  it  is  highly  probable  that  the  animal's  normal  sensibilities  had 
been  perverted,  the  result  of  suffering,  infection  or  temperature;  as 
we  frequently  see  delirious  patients  mutilating  themselves  or  tearing 
open  wounds  without  apparently  any  evidence  of  pain. 

Some  observations  which  I  have  made  in  resecting  eviscerated 
loops  of  the  intestine  in  two-stage  operations  may  be  of  interest. 
During  the  last  few  years  I  have  had  repeated  occasion  to  resect  the 
large  intestine,  usually  the  transverse  colon,  for  obstruction  usually 
the  result  of  tuberculous  or  other  tumors.  The  condition  of  the  pa- 
tient has  required  that  this  be  done  in  two  stages  by  the  Bodine  or 
Mikulicz  plan,  by  first  liberating  and  fixing  the  mass  outside  the 
abdomen,  approximating  the  two  ends  of  the  bowel  within  the  cavity 


THE   ABDOMEN  341 

and  closing  the  abdominal  wound  around  them;  the  resection  of  the 
mass  being  done  at  a  subsequent  sitting.  At  the  time  of  the  re- 
section careful  observations  were  always  made  regarding  the  sensa- 
tions experienced.  In  some  of  these  cases  considerable  portion  of 
the  mesentery  was  included  in  the  mass  to  be  resected.  The  re- 
sections were  usually  done  with  the  cautery  under  a  low  degree  of 
heat  to  control  the  hemorrhage  but  occasionally  cutting  instruments 
were  used  with  ligation  for  the  bleeding  points.  These  resections 
were  invariably  done  without  general  anesthesia  and  the  results  of 
the  observations  in  several  such  cases  were  quite  uniform.  The 
entire  circumference  of  the  intestine  was  insensitive  to  cutting,  burn- 
ing or  crushing  but  where  the  mesentery  was  included  pain  of  an 
aching  or  cramping  character  was  always  felt  in  the  epigastrium,  the 
pain  was  the  same  whether  the  mesentery  was  cut,  burned  or  crushed 
and  this  pain  was  always  stopped  by  proximal  injections  of  the 
mesentery  with  some  local  anesthetic.  Symptoms  of  shock  often 
followed  this  procedure  if  the  mass  was  large  and  more  so  following 
the  use  of  the  cautery.  The  sensations  following  the  application  of 
the  clamp  were  also  of  interest.  In  case  the  approximated  surfaces 
of  the  bowel  to  which  the  clamp  was  applied  had  been  so  arranged 
that  they  were  well  away  from  the  mesentery  very  little  sensation 
was  complained  of  as  a  rule,  but  here  the  result  of  the  observations 
was  not  uniform,  but  when  we  felt  certain  that  some  mesentery  was 
included  within  the  grasp  of  the  clamp  from  previous  notes  as  to  its 
location,  more  pain  was  always  caused.  This  pain  was  always  of  a 
cramping  character  and  always  in  the  epigastrium  no  matter  where 
the  site  of  the  resection.  The  pain  did  not  always  come  on  immedi- 
ately following  the  application  of  the  clamp.  In  one  case  it  was 
twenty  minutes  before  any  complaint  was  made  when  the  pain  was 
then  considerable  and  associated  with  some  shock. 

Many  other  clinical  observations  could  be  recorded  from  which 
similar  conclusions  have  been  drawn,  namely  that  the  abdominal 
viscera  are  insensitive  to  pain  except  at  the  hilum  or  mesenteric 
attachments.  The  bladder  is  an  exception  to  this  rule  as  all  parts  are 
sensitive,  the  fundus  least  so,  and  any  trauma  to  its  walls  is  felt  in  an 
urgent  desire  to  urinate. 

In  carefully  considering  the  above  observations  in  connection  with 
the  findings  by  Kast  and  Meltzer  we  find  a  considerable  difference  in 
the  results  obtained.  As  the  extrusion  of  the  mesentery  with  the 
tumor  mass  did  not  cause  it  to  lose  or  change  its  sensations  from  those 
it  is  known  to  show  within  the  cavity  it  is  probable  that  the  intestines 


342  LOCAL  ANESTHESIA 

were  likewise  unaffected  and  that  they  are  insensitive  both  within 
and  without  the  cavity. 

Investigations  have  been  undertaken  with  a  view  of  determining 
the  sensibility  of  the  mucous  membrane  at  various  points  along  the 
alimentary  canal,  and,  while  the  results  of  these  investigations  agree 
on  nearly  all  points,  there  are  still  some  dissenting  opinions.  These 
tests  were  made  through  gastric  and  intestinal  fistula  or  artificial  ani, 
or  by  passing  instruments  into  the  stomach  through  a  stomach-tube, 
or  into  the  rectum  through  a  speculum;  the  results  of  these  examina- 
tions have  been  that  the  mucous  membrane  of  these  parts  has  no 
sense  of  touch,  pain,  heat,  or  cold.  In  1909  Zimmerman  published 
the  results  of  an  extensive  series  of  experiments  upon  himself  and  on 
patients.  These  experiments  were  principally  upon  the  stomach  and 
rectum,  and  were  performed  without  any  anesthesia;  the  mucous 
membrane  of  these  parts  was  irritated  in  a  variety  of  ways — by  pinch- 
ing with  forceps,  by  electrodes,  and  by  the  cautery.  In  the  stom- 
ach there  was  no  response  to  any  form  of  irritation,  but  decided  pres- 
sure gave  rise  to  a  sense  of  fulness.  In  the  rectum,  6  cm.  above  the 
external  sphincter,  there  was  no  sense  of  any  kind  except  for  pressure 
and  differences  in  pressure  could  be  noted. 

The  esophagus  was  sensitive  to  both  heat,  cold,  and  pressure. 
Regarding  these  experiments  upon  the  rectum,  the  author  has  tested 
the  sensibility  of  the  rectal  mucosa  and  found  that  above  the  anal 
canal  there  is  practically  no  sense  of  pain  to  superficial  irritation,  and 
the  mucous  membrane  can  be  cut  and  cauterized  without  any  com- 
plaint. On  one  occasion  a  polypus  was  removed  by  cutting,  with 
cauterization  of  its  attachments,  with  an  electrode  without  any  com- 
plaint from  the  patient,  although  this  region  felt  sore  for  several  days 
afterward.  Schwenkenbecker  in  1908  described  his  sensations  after 
taking  large  doses  of  menthol,  which  produced  on  the  sensitive  mu- 
cous membrane  of  the  mouth  an  intense  feeling  somewhat  between 
burning  and  cold.  After  the  drug  had  passed  the  level  of  the  larynx 
there  was  no  sensation  until  the  anal  canal  was  reached,  when  the 
feeling  of  cold  was  again  produced.  He  concludes  from  this  observa- 
tion that  the  mucous  membrane  of  the  alimentary  canal  is  insenitive 
except  at  its  upper  and  lower  ends. 

We  know  that  certain  affections  of  the  stomach,  notably  ulcer, 
give  rise  to  pain,  although  they  may  exist  for  long  periods  of  time 
without  the  patient's  knowledge,  and  intestinal  ulcers  may  go  on  to 
perforation  without  the  patient  having  been  aware  of  their  existence; 
similarly,  the  ulcers  of  typhoid  fever  seem  to  excite  no  pain.  Len- 


THE    ABDOMEN  343 

nander  maintains  that  a  gastric  ulcer  excites  no  pain  unless  accom- 
panied by  a  lymphangitis,  and  that  hyperacidity  excites  pain  when 
the  irritating  or  chemical  substances  are  carried  by  the  lymphatics  to 
the  sensitive  abdominal  wall  (posteriorly).  Mueller,  in  discussing 
this  point,  admits  that  the  stomach  shows  no  reaction  to  touch,  cold, 
or  heat,  as  far  as  external  stimulation  is  concerned,  but  asserts  that 
it  does  react  to  certain  internal  irritations.  He  believes  that  the 
abdominal  organs  do  possess  certain  sensations  necessary  for  protec- 
tion from  toxic  or  chemically  irritating  substances,  and  are  capable 
of  mechanical  irritation  by  overdistension.  The  sensations  thus 
produced  he  attributes  to  the  sympathetic  nerves,  which,  under  or- 
dinary normal  conditions,  do  not  transmit  painful  impressions,  but 
become  capable  of  feeling  pain  under  the  irritation  of  abnormal  or 
diseased  conditions.  When  all  the  evidence,  pro  and  con,  regarding 
the  sensibility  of  the  abdominal  organs  has  been  gathered  and  care- 
fully sifted  down,  we  have  to  admit  that  the  crucial  test  must  be  the 
application  of  these  findings  by  the  practical  surgeon  at  the  operating- 
table  upon  the  human  subject,  and  here,  so  far,  Lennander's  views 
have  largely  been  substantiated.  In  the  experience  of  the  writer  the 
intestines  are  devoid  of  sensation  unless  the  mesentery  is  pulled  upon; 
after  extensive 'manipulations  the  patient  may  complain  of  a  peculiar 
visceral  sense,  hardly  a  pain,  but  at  times  sufficient  to  excite  some 
complaint.  We  have  frequently  explored  limited  parts  of  the  ab- 
dominal cavity  by  introduction  of  the  fingers  or  hand,  and  when  care- 
fully done,  avoiding  friction  on  the  parietal  peritoneum,  it  caused  no 
complaint,  except  in  the  region  of  the  foramen  of  Winslow  over  the 
celiac  plexus;  here  the  parts  seem  particularly  sensitive.  The  parie- 
tal peritoneum  and  mesentery  have  always  been  found  sensitive, 
except  when  controlled  by  the  injections  of  the  anesthetic  solutions; 
it  is  certain  that  only  those  parts  controlled  by  the  injections  would 
stand  operation;  that  the  solution  used  may  have  had  some  control- 
ling or  lessening  effect  upon  the  sensibility  of  other  parts  may  be 
possible,  but  we  have  never  observed  the  general  analgesia,  such  as 
that  reported  by  Kast  and  Meltzer  upon  dogs,  when  using  cocain  or 
any  other  local  anesthetic  agent,  and  any  extension  of  the  incisions 
to  the  recognized  sensitive  parts,  if  unanesthetized,  has  always  ex- 
cited pain  and  required  additional  infiltration.  In  some  few  very 
extensive  intra-abdominal  operations  undertaken  with  local  anesthe- 
sia, where  large  quantities  of  the  anesthetic  solution  were  used  and 
large  parts  of  the  intestines  and  other  organs  exposed,  the  prolonga- 


344  LOCAL   ANESTHESIA 

tion  of  the  operation,  instead  of  lessening  the  sensibility,  seemed 
rather  to  increase  it. 

In  numerous  operations  for  artificial  anus  where  a  loop  of  bowel, 
usually  the  descending  colon,  has  been  fixed  outside  the  abdominal 
wall,  either  under  local  or  general  anesthesia,  and  opened  several 
days  later  without  any  form  of  anesthesia,  I  can  remember  no  case 
where  any  complaint  was  made.  Here  my  observations  have  been 
quite  similar  to  those  cases  in  which  larger  sections  were  removed  as 
noted  above.  This  opening  was  made  either  with  knife,  scissors,  or 
cautery,  and  later,  after  retraction  had  taken  place,  the  excess  of 
tissue  was  trimmed  down  level  with  the  abdominal  wall.  Whether 
the  long  exposure  and  changes  occuring  on  the  surface  of  the  bowel 
was  sufficient  to  destroy  the  sensibility  of  the  part  or  not  is  possible, 
but  it  is  certain  that  these  cases  have  not,  as  a  rule,  required  any  form 
of  anesthesia  for  the  opening  of  the  bowel.  The  same  may  be  said 
about  the  stomach  in  operations  for  gastrostomy,  as  in  the  Ssabana- 
jew-Frank  operation,  where  the  stomach  is  opened  a  few  days  later, 
after  adhesions  have  taken  place. 

A  careful  study  of  the  preceding  pages  should  prove  particularly 
interesting  to  the  practical  surgeon  who  attempts  to  deal  with  intra- 
abdominal  conditions  under  local  anesthesia.  Nowhere  better  than 
in  the  abdominal  cavity  is  the  fact  demonstrated  that  the  skilful  use 
of  local  anesthesia  is  in  itself  an  art.  What  one  operator  does  with 
ease  seems  to  another  impossible,  and  he  may  even  discredit  the 
statements  of  the  other.  Here,  in  addition  to  a  thorough  knowledge 
of  technic,  it  is  absolutely  essential  to  possess  an  accurate  knowledge 
of  the  manipulations  which  cause  pain,  the  parts  most  susceptible  of 
painful  impressions,  and  the  conditions  which  intensify  these  im- 
pressions, such  as  inflammation. 

We  all  agree  that  certain  of  the  intra-abdominal  contents  possess 
painful  sensations;  these  are  especially  all  blood-vessels  except  the 
smallest  divisions  (and  this  rule  holds  good  elsewhere  in  the  body), 
and  the  mesenteries  and  attachments  of  the  viscera  to  the  abdominal 
wall.  As  the  blood-vessels  almost  invariably  lie  within  the  folds 
of  the  mesentery,  this  limits  the  areas  of  sensibility  under  ordinary 
conditions  (the  absence  of  inflammation)  to  the  mesentery  and  the 
parietal  peritoneum.  1  have  never  found  that  incision,  clamping,  or 
suture  of  the  stomach,  large  or  small  intestines,  gall-bladder,  or  uterus 
upon  which  I  have  operated  ever  gave  pain,  providing  the  surround- 
ing parts  were  not  disturbed  by  rough  manipulations  that  would 
make  traction  upon  the  mesentery,  and  when  it  was  necessary  to  in- 


THE    ABDOMEN  345 

elude  the  mesentery  in  the  field  of  operation,  as  in  resections,  a 
moderate  injection  of  anesthetic  solution  between  its  folds  and  at 
some  distance  proximal  to  the  field  always  sufficed  to  control  these 
sensations,  providing  there  was  no  traction. 

It  is  essential  for  these  reasons  that  rather  free  incisions  be  made 
to  permit  the  ready  manipulation  of  the  parts  as  much  within  the 
cavity  as  possible  and  render  unnecessary  undue  traction  and 
displacement. 

Abdominal  Nerve-supply. — We  should  now,  for  a  thorough 
understanding  of  our  subject,  be  able  to  account  for  the  pain- 
conducting  nerve-fibers  within  the  cavity. 

We  know  that  all  the  abdominal  organs  are  innervated  almost 
exclusively  by  the  sympathetic  system,  and  that  all  the  sympathetic 
ganglia  as  they  lie  against  the  vertebral  column,  both  within  the  abdo- 
men and  above,  receive  fibers  from  the  spinal  nerves  just  after  emerg- 
ing from  the  vertebral  foramina  (Figs.  74-76).  It  has  been  impos- 
sible to  trace  these  nerve-fibers  to  their  ultimate  distribution — most 
are  soon  lost  in  the  intermingling  of  nerve-fibers  of  that  region,  some 
few  have  been  traced  to  the  mesentery,  but  could  not  be  followed 
further,  as  it  is  impossible  by  any  known  methods  to  distinguish 
between  sensory  and  other  nerve-fibers.  As  all  painful  impressions 
must  come  through  the  cerebrospinal  nerves,  it  is  in  fibers  supplied  by 
these  communicating  branches  and  other  small  branches  given  off 
at  the  back  of  the  abdominal  cavity  by  the  lumbar  nerves  that  we 
must  look  for  the  paths  of  these  sensations. 

An  effort  has  more  recently  been  made  to  reach  these  rami  com- 
municantes,  and  at  the  same  time  block  the  parent  trunk  by  reaching 
these  nerves  just  as  they  emerge  from  the  vertebral  foramina;  thus,  by 
a  paravertebral  injection  (by  one  injection)  securing  both  visceral  as 
well  as  parietal  anesthesia  of  the  entire  distribution  of  the  nerve. 
This  method  is  spoken  of  more  in  detail  under  this  heading. 

The  nerve-supply  of  the  abdominal  walls  is  from  the  six  lower 
intercostals  and  the  upper  branches  of  the  lumbar  plexus.  (See 
Figs.  74-76).  In  their  course  through  the  abdominal  walls  these 
nerves  all  lie  near  the  inner  wall,  the  intercostals  running  between 
the  transversalis  and  internal  oblique  to  the  outer  edge  of  the 
rectus.  The  lumbar  nerves  emerge  just  beneath  or  through  the 
fibers  of  the  psoas  muscle,  they  then  lie  on  the  surface  of  the  quadra- 
tus  lumbarum  until  they  reach  the  transversalis  muscles  beneath 
which  they  pass,  after  which  they  pursue  the  same  general  course 
as  the  intercostals.  At  the  outer  edge  of  the  rectus  muscle  (linea 


346 


LOCAL  ANESTHESIA 


semilunares)  branches  are  given  off  which  pass  forward  through 
the  anterior  rectal  sheath  to  the  subcutaneous  tissues,  these  branches 
are  always  encountered  at  or  near  the  linea  transversae,  though 


greater  splanchnic    ,/„„/,„,„,„  x      Cnriliax 

'  '    intercostal  nerve  XI 


'us  communicant 


Coccyget 

:ra»I^M-T-     • ,        (     (  , 

return  x  \  »         »      \pudendal-    \ 

toccygeal  ganglion  coecygeai  nerve    sacral  nerve  V        plexus        xieral  plexus 

Fig.  76. — The  abdominal  and  pelvic  portions  of  the  sympathetic  trunk.  The 
anterior  abdominal  and  pelvic  walls  have  been  removed,  the  lumbar  plexus  exposed  by 
removal  of  the  psoas  major,  and  the  aorta  left  in  situ  up  to  its  bifurcation.  *  =  Visceral 
branches  of  the  pudendal  plexus.  (Sobotta  and  McMurrich.) 

others  are  met  with  between  these  points.  The  main  trunks  then 
continue  their  course  downward  and  inward  lying  on  the  posterior 
rectal  sheath  just  beneath  the  muscle  giving  off  its  terminal  branches 


THE   ABDOMEN  347 

in  this  position,  which  run  forward  through  the  muscle  toward  the 
skin. 

As  a  general  proposition,  it  may  be  said  that  in  operations  upon 
any  intra-abdominal  part  a  thorough  infiltration  of  the  abdominal 
wall  in  the  line  of  incision  is  the  first  essential  feature.  Should  the 
operation  be  upon  the  fundus  of  a  part  or  at  some  distance  from  its 
mesenteric  attachment,  no  further  anesthesia  may  be  required,  but 
should  the  field  of  operation  involve  the  cervix,  hilum,  or  mesenteric 
attachment  of  the  part,  these  must  be  thoroughly  blocked.  These 
principles,  when  properly  applied  to  the  various  parts,  are  the  essen- 
tials of  the  anesthetizing  process. 

Anesthetizing  the  Abdominal  Wall.— Braun,  in  infiltrating  the  ab- 
dominal wall  preparatory  to  its  incision,  makes  the  injection  around 
the  field  in  more  or  less  rhombus  shape.  This  is  best  illustrated  by 
making  an  injection  around  the  middle  line— we  will  say,  for  an  opera- 
tion upon  the  stomach.  A  line  of  cutaneous  anesthesia  is  established 
on  each  side  two  or  three  fingers-breadth  from  the  middle  line; 
starting  on  this  line  at  two  or  more  points,  depending  upon  the  extent 
of  the  proposed  incision,  the  long  needle  is  entered  and  directed 
obliquely  outward,  injecting  as  it  is  advanced,  piercing  the  rectus 
sheath,  which  is  recognized  by  its  slight  resistance  to  the  needle,  and 
advancing  some  little  distance  within  this  muscle  until  it  is  quite 
freely  injected;  the  needle  is  then  partially  withdrawn,  when  it  is  ad- 
vanced again  in  two  or  more  directions  above  and  below,  slightly 
increasing  the  angle  each  time,  thus  making  the  injection  in  something 
of  a  fan-like  shape ;  this  is  done  along  the  line  of  cutaneous  anesthesia 
at  two  or  more  points,  having  the  fan-like  areas  of  infiltration  come 
in  contact  with  the  one  above  or  below.  The  same  procedure  is  re- 
peated on  the  opposite  side.  These  two  lateral  lines  of  infiltration 
are  joined  above  and  below  by  subcutaneous  infiltration,  as  shown 
in  Fig.  77. 

While  the  above  method  of  Braun  is  certainly  found  useful  in 
thin  subjects,  in  thick  abdominal  walls  heavily  overlaid  with  fat 
it  is  unsatisfactory,  takes  longer  to  carry  out,  and  requires  some  little 
delay  before  the  solution  has  thoroughly  diffused  in  all  directions 
and  anesthesia  established.  I  usually  prefer  to  establish  a  wall  of 
anesthesia  along  the  proposed  line  of  incision  from  the  skin  to  the 
peritoneum,  and  have  not  found  that  muscular  contractions  interfere 
if  anesthesia  has  been  perfect,  and  no  pain  excited  either  in  the  in- 
cision or  operation  on  the  deeper  parts,  the  muscles  usually  being 
quite  relaxed.  The  method  of  procedure  is  usually  as  follows:  An 


348 


LOCAL   ANESTHESIA 


intradermalwheal  is  established  midway  along  the  line  of  the  proposed 
incision;  the  long  needle  with  10  c.c.  syringe  is  entered  at  this  point 
and  directed  up  and  then  down,  without  withdrawing  the  needle, 
along  the  proposed  line  of  incision  in  the  subcutaneous  tissues,  in- 
jecting freely  as  the  needle  is  advanced,  detaching  and  refilling  the 
syringe  as  occasion  requires;  without  withdrawing  the  needle  from 
the  skin  its  direction  is  now  changed,  and  it  is  passed  inward  toward 
the  rectal  sheath;  this  is  the  first  plane  of  decided  resistance  which  the 
needle  encounters;  this  is  gently  pierced,  injecting  as  the  needle  is 


Fig.  77. — i.  Braun's  method  of  anesthetizing  abdominal  wall  around  area  of  incision; 
2,  author's  method:  infiltration  of  line  of  incision  from  one  midpoint. 

advanced  to  about  i  cm.  within  the  sheath;  the  needle  is  then  par- 
tially withdrawn  and  redirected  within  the  sheath  at  several  points 
above  and  below  in  a  similar  manner  (Fig.  77).  Returning  now  to 
the  skin,  the  intradermal  infiltration  is  completed  along  the  proposed 
line  of  incision.  The  deeper  injections  thus  made  first  have  ample 
time  to  diffuse.  Having  completed  the  skin  infiltration,  the  incision 
is  made  down  to  the  rectus  sheath  without  need  of  further  delay;  with 
the  rectal  sheath  now  within  plain  view,  further  injections  can  be 
made  within  it  if  necessary.  At  this  point  the  superficial  vessels  are 


THE   ABDOMEN  349 

ligated,  getting  rid  of  the  forceps  and  allowing  the  deeper  injections 
more  time  to  diffuse  during  this  interval.  The  rectal  sheath  is  now 
slit  up  and  the  muscle-fibers  separated,  exposing  the  posterior  sheath; 
this  is  now  penetrated  at  several  points  with  the  needle  and  freely  in- 
filtrated posteriorly  in  the  retroperitoneal  tissue,  this  last  injection 
freely  diffusing  to  the  peritoneum;  the  posterior  sheath  and  perito- 
neum are  now  opened. 

This  method  I  have  found  to  be  highly  satisfactory  and  quickly 
executed,  and  employ  it  almost  invariably  for  incisions  through  any 
part  of  the  abdominal  walls. 

The  solution  usually  preferred  for  these  incisions,  as  well  as  for  all 
work  within  the  cavity,  is  No.  2  (0.50  per  cent,  novocain  in  0.04  per 
cent.  NaCl),  adding  about  10  drops  of  adrenalin  to  every  3  or  4  ounces 
of  the  solution  used. 

POSSIBLE  SCOPE  OF  OPERATIONS  WITHIN  THE  ABDOMEN 

After  a  careful  consideration  of  the  preceding  pages  it  is  seen  that 
many  difficulties  may  attend  the  performance  of  any  complicated  or 
extensive  operation  within  the  abdominal  cavity  and  any  operation 
undertaken  with  any  certainty  of  success  by  purely  local  means  must 
be  limited  to  those  parts  which  are  in  contact  with  the  abdominal 
walls  or  are  readily  accessible  and  can  be  operated  on  without  undue 
manipulation  or  traction.  In  the  presence  of  an  acute  inflammation, 
extensive  adhesions  or  when  the  diagnosis  is  at  all  in  doubt  local 
anesthesia  is  not  indicated. 

All  simple  operations,  such  as  gastrostomy,  gastrotomy,  colos- 
tomy,  appendectomy,  and  gall-bladder  drainage,  are  quite  satisfac- 
torily performed  on  suitable  subjects  (when  not  too  nervous  or  ap- 
prehensive) when  the  parts  are  fairly  easily  accessible,  and  not 
matted  down  by  inflammation  or  adhesions  to  the  parietal  periton- 
neum  or  surrounding  organs;  consequently,  only  such  operations 
should  be  undertaken  when  it  is  known  beforehand  that  favorable 
conditions  exist.  A  fairly  satisfactory  exploration  can  be  done 
under  local  anesthesia  by  making  a  free  incision  to  permit  the  easy 
introduction  of  the  hand,  when,  if  it  is  gently  insinuated  without 
pressure  or  traction,  a  rather  thorough  examination  of  the  entire 
cavity  can  be  made.  The  sensations  experienced  by  a  patient 
during  a  carefully  made  examination  of  this  kind  is  that  of  a  vague 
intra-abdominal  sensation,  variously  described  as  a  weight  or  fulness, 
becoming  cramp-like  if  traction  or  pressure  is  exerted.  This  pain 
is  always  referred  to  the  epigastrium  and  is  the  same  no  matter  what 


350  LOCAL   ANESTHESIA 

the  trauma  inflicted  and  is  best  described  as  the  abdominal  pain. 
Its  seat  seems  to  be  about  the  position  of  the  solar  plexus. 

It  may  often  be  found  satisfactory  to  make  such  an  exploration 
under  local  means,  then  resorting  to  a  light  general  anesthesia  if 
conditions  are  met  with  which  cannot  be  easily  undertaken  by  local 
means  alone. 

Local  anesthesia  is  not  the  method  for  routine  work  within  the 
abdomen,  although  in  the  interest  of  the  patient  many  of  the  more 
serious  operations  may  be  undertaken  by  these  methods  alone;  here 
it  should  always  be,  borne  in  mind  that  no  traction  upon  a  viscus  is 
ever  tolerated. 

If,  on  exploring  through  a  midline  incision,  an  appendix  or  dis- 
eased gall-bladder  is  encountered,  separate  incisions  should  be  made 
over  these  parts  rather  than  attempt  to  displace  them  toward  the 
midline. 

As  a  general  rule  all  very  stout  individuals  and  those  with  tense 
rigid  abdominal  walls  are  difficult  to  handle  in  any  serious  intra- 
abdominal  operation,  for  as  soon  as  the  abdomen  is  opened  the  con- 
tents bulge  out  and  as  any  extensive  packing  back  or  the  use  of  deep 
retractors  excite  pain  the  difficulties  are  at  once  increased  by  the 
straining  which  these  procedures  bring  on.  Thin  subjects  with  re- 
laxed abdominal  walls  make  very  favorable  subjects  and  opera- 
tions of  considerable  magnitude  may  at  times  be  performed.  It  is 
only  in  these  subjects  with  relaxed  walls  that  the  viscera  can  be 
easily  displaced  permitting  access  to  the  posterior  abdominal  wall 
where  further  infiltration  can  be  safely  done  to  block  the  visceral 
innervation. 

By  consulting  the  pages  on  the  abdominal  nerve  supply  it  will  be 
seen  that  these  deep  injections  to  be  most  effective  must  be  along 
the  line  of  the  sympathetic  chain  where  the  rami  communicantes 
join  the  sympathetic  nerves;  these  injections  must  consequently  be 
made  close  to  the  vertebral  column.  In  thin  relaxed  subjects  when 
much  gentleness  is  used  it  is  usually  possible  to  slip  in  two  fingers  or 
a  long  narrow  retractor  opening  the  way  for  the  needle  and  the  re- 
troperitoneal  tissue  of  these  parts  infiltrated,  care  being  exercised  in 
the  neighborhood  of  the  large  vessels.  In  the  lower  part  of  the  ab- 
domen this  infiltration  is  done  on  the  inner  and  outer  sides  of  the 
psoas  muscle;  in  the  upper  part  of  the  cavity  close  around  the  great 
vessels  on  the  vertebrae.  It  is  not  necessary  always  to  get  into 
direct  contact  with  these  parts  as  the  retroperitoneal  tissue  here  is 
quite  loose  and  a  fairly  liberal  injection  of  weak  solution  will  diffuse 


THE   ABDOMEN  351 

in  all  directions  and  reach  the  desired  parts.  When  possible  I  have 
always  found  the  high  injections  in  the  neighborhood  of  the  solar 
plexus  to  be  most  effective.  As  can  be  readily  understood  these 
procedures  are  always  difficult  even  in  favorable  subjects  and  are 
then  only  possible  in  the  hands  of  those  who  have  had  much  experi- 
ence with  local  methods  within  the  cavity. 

A  centra-indication  to  satisfactory  intra-abdominal  work  is  met 
with  in  ticklish  individuals.  I  have  frequently  noticed  that  the 
intra-abdominal  sensibility  was  much  greater  in  these  patients,  who 
are  as  a  rule  neurotic,  and  frequently  prevented  the  successful 
approach  to  the  deeper  parts  where  the  visceral  sensibility  could  be 
controlled. 

Many  conditions  of  the  patient  may  confra-indicate  general  anes- 
thesia; it  may  then  be  advisable  to  attempt  the  more  serious  and 
complicated  procedures  when  the  indications  are  urgent.  Very  ill 
patients,  and  those  suffering  from  the  toxic  effect  of  disease,  often 
have  their  general  sensibility  so  reduced  that  they  make  favorable 
subjects,  provided  they  are  not  dangerously  weakened  or  the  field 
of  operation  is  not  actively  involved  in  inflammation;  even  in  some 
greatly  weakened  and  reduced  patients  the  danger  of  a  general  anes- 
thesia may  be  greater  than  the  difficulties  likely  to  be  encountered 
with  local  anesthesia;  it  may,  therefore,  be  advisable  to  proceed  by 
these  methods.  In  some  cases  the  combined  method  of  operating  is 
advisable,  using  infiltration  with  light  or  superficial  narcosis  (see 
chapter  on  this  subject).  In  all  intra-abdominal  operations  of  any 
severity  the  preliminary  hypodermic  of  morphin,  %  to  Y±  gr.  or 
pantopon  %  gr.  with  scopolamin  3^50  to  Koo  gr->  should  always  be 
given  one  hour  before  operation. 

The  Stomach.- — Simple  operations  upon  the  anterior  wall  of  the 
stomach  when  uncomplicated  are  quite  easily  performed  under  local 
anesthesia  by  infiltration  of  the  entire  abdominal  wall  and  subperi- 
toneal  tissue  in  the  line  of  the  proposed  incision,  as  already  explained, 
making  the  incisions  slightly  longer  than  under  a  general  anesthetic; 
the  cavity  is  opened,  the  wound  lightly  retracted,  and  the  stomach 
operated  upon  in  position,  or  the  viscus  caught  with  a  sponge-holder 
or  the  fingers  and  gently  drawn  out;  if  care  is  exercised  not  to  pull  upon 
its  attachments,  no  pain  is  produced.  In  this  way  we  have  operated 
in  many  cases,  and  always  with  perfect  satisfaction.  It  is  quite  easy 
to  perform  gastrotomy  for  the  removal  of  foreign  bodies  or  the  ex- 
amination of  the  interior  of  the  stomach;  also  gastrostomy  by  the 
Ssabanajew-Frank  or  other  methods,  or  the  Heinecke-Mikulicz 


352  LOCAL   ANESTHESIA 

operation  for  hour-glass  contraction,  when  unaccompanied  by  sur- 
rounding complicating  conditions. 

Gastro-enterostomy  and  gastric  resections  are  now  no  longer 
novelties  under  local  anesthesia.  The  early  and  extensive  work 
done  by  Mikulicz,  and  later  by  Braun,  Lawen,  Bakes,  and  a  host  of 
others,  especially  Finsterer  with  his  classic  contributions  upon  this 
subject,  have  placed  this  method  of  operating  upon  a  firmly  estab- 
lished foundation,  and  securing  for  it  a  recognition  amoung  other 
accepted  procedures. 


Fig.  78. — i,  Line  of  anesthesia  for  exposing  stomach.  Upper  oblique  line  is  for  addi- 
tional incision  for  Ssabanajew-Frank  gastrostomy;  2,  for  exposure  of  gall-bladder; 
3,  appendectomy  through  straight  rectus  incision. 

In  posterior  gastro-enterostomy  by  the  "no-loop  method,"  the 
operation  now  generally  performed,  the  posterior  stomach  wall  is  as 
tolerant  of  operative  intervention  without  discomfort  as  in  the  an- 
terior; to  secure  access  to  it  the  mesocolon,  in  the  usually  selected 
non- vascular  area,  is  first  freely  infiltrated  between  its  layers  before 
it  is  divided  and  the  stomach  seized.  In  drawing  the  omentum  and 
transverse  colon  out  of  the  field  and  displacing  it  above,  as  is  usually 
done,  they  should  be  carefully  covered  with  wet  towels  (saline  solu- 
tion) ,  as  their  prolonged  contract  with  the  air  may  excite  some  com- 


THE   ABDOMEN  353 

plaint.  After  infiltration  of  the  mesocolon  no  further  infiltration  is 
necessary,  and  the  various  steps  of  the  operation  are  carried  out  the 
same  as  under  a  general  anesthetic. 

For  gastric  resections  the  gastrocolic  and  lesser  omentums  must 
be  freely  infiltrated  between  their  folds  for  an  area  some  little  dis- 
tance beyond  the  proposed  field  of  resection;  this  should  not  be  under- 
taken by  local  anesthesia  alone,  except  under  conditions  of  free  mo- 
bility of  the  stomach. 

Finsterer,  in  his  latest  contribution  to  this  subject  in  the"Beitrage 
zur  Klin.  Chir./'  1912,  cites  in  detail  a  large  number  of  resections 
and  gastro-enterostomies  performed  by  purely  local  means.  The 
notable  differences  observed  between  such  operations  and  similar 
ones  performed  under  general  anesthesia  was  the  marked  absence 
from  shock,  lung,  and  renal  complications,  and  almost  a  total  absence 
of  postoperative  vomiting  and  gastric  distention,  viscious  circle,  etc., 
as  there  is  not  that  paralysis  of  the  stomach  walls  which  follow  such 
operations  under  general  anesthesia. 

In  colostomy  for  the  establishment  of  an  artificial  anus  the  same 
may  be  said  here  as  for  the  stomach — the  operation  is  quite  easy  and 
satisfactory  where  the  mesentery  is  not  pulled  upon.  The  later 
opening  of  the  bowel  after  a  day  or  two,  when  adhesions  have  taken 
place,  we  have  never  found  accompanied  by  any  pain;  the  excess  of 
tissue  can  be  trimmed  down  level  with  the  abdominal  wall  by  either 
knife,  scissors,  or  cautery. 

The  Appendix. — The  opening  of  a  simple  appendicular  abscess 
when  in  contact  with  the  abdominal  wall  involves  no  greater  difficul- 
ties than  an  abscess  situated  elsewhere,  and  is  always  suitable  for 
operation  under  local  anesthesia.  The  removal  of  the  appendix  is 
a  different  matter;  in  the  presence  of  inflammation  or  extensive  ad- 
hesions the  operation  is  never  suitable  for  local  measures  alone; 
again,  we  never  know  where  the  appendix  will  be  found,  whether 
lying  loose  on  the  intestines  in  its  usual  position,  bound  down  to  the 
surrounding  structures,  attached  in  the  pelvis,  embedded  in  the 
posterior  abdominal  wall  or  retrocecal.  The  ease  with  which  the 
appendix  can  be  removed  in  non-inflammatory  cases  depends  entirely 
upon  its  position;  when  lying  loose  and  easily  accessible  we  have  quite 
frequently  removed  it  without  any  difficulties  or  pain  to  the  patient, 
but  always  infiltrate  lightly  the  meso-appendix,  as  its  ligation  will 
cause  pain,  taking  care  not  to  enter  a  vein  in  making  the  injection; 
when  lying  in  other  less  accessible  positions,  by  sufficiently  enlarging 
the  abdominal  incision  to  permit  free  access,  it  can  be  fairly  satis- 


354  LOCAL  ANESTHESIA 

factorily  separated  from  other  attachments,  when  not  too  extensive, 
by  lightly  infiltrating  these  lines  of  attachment  with  the  anesthetic 
solution.  On  one  occasion  the  author  removed,  with  but  very 
moderate  discomfort  to  the  patient,  a  retrocolic  appendix  by  infiltra- 
tion of  the  attachments  of  the  cecum  and  colon  to  the  abdominal 
wall  as  well  as  the  retrocolic  space,  then  divided  these  attachments 
and  rolled  the  colon  inward.  Similar  methods  of  procedure  may  be 
resorted  to  elsewhere. 

Gall-bladder. — Operations  upon  the  fundus  of  the  gall-bladder 
for  purposes  of  drainage  in  cholecystitis,  or  for  the  removal  of  stones, 
are  quite  easily  and  painlessly  performed  when  the  bladder  is  fairly 
accessible  and  not  contracted  or  bound  down  by  adhesions. 

As  traction  will  cause  pain  this  should  be  carefully  avoided; 
scooping  out  stones  or  passing  in  forceps  to  extract  them,  if  cautiously 
done,  will  excite  no  complaint.  Where  stones  are  found  in  the  cystic 
or  common  duct,  or  the  bladder  small  and  contracted  or  badly  ad- 
herent, the  case  is  hardly  suitable  for  local  anesthesia  alone. 

The  Liver. — Operations  upon  the  right  lobe  for  abscess  are  best 
operated  by  the  transthoracic  route,  which  has  been  described  in 
operations  upon  the  thorax.  Abscesses  of  the  left  lobe  are  quite 
easily  operated  over  their  most  prominent  points;  in  these  cases  the 
liver  is  usually  already  adherent  to  the  abdominal  wall,  and  a  simple 
incision  under  infiltration  is  all  that  is  necessary;  when  it  is  not  ad- 
herent, it  is  first  secured  by  sutures  through  its  capsule  before  open- 
ing; this  is  not,  as  a  rule,  painful,  but  should  complaint  be  made  light 
infiltration  of  the  capsule  will  be  sufficient  to  control  it. 

Intestines. — Resection  of  the  bowel  has  been  done  satisfactorily 
under  local  anesthesia.  In  typhoid  perforation  Dr.  Harvey  Gushing 
reviews  5  cases,  and  notes  their  decidedly  favorable  postoperative 
condition  when  compared  with  such  cases  (perforation  or  suspected 
perforation)  operated  on  with  a  general  anesthesia,  and  comes  to  the 
following  conclusions : 

"In  consideration  of  the  inevitable  fatality  of  intestinal  perfora- 
tion in  typhoid  fever,  and  in  the  face  of  extreme  difficulties  of  diagno- 
sis which  often  attend  this  complication  in  its  early,  and  from  the 
surgical  standpoint  its  elective  stage,  it  can  be  understood  that  a 
prompt  exploration,  could  it  be  unattended  by  risk,  would  be  most 
desirable.  From  the  discussion  and  reports  of  these  cases  it  would 
appear  that  in  certain  surroundings  such  an  exploration  under  local 
anesthesia  can  be  satisfactorily  accomplished  painlessly  and  without 
exposing  the  patient  to  danger." 


THE   ABDOMEN  355 

Dr.  Mitchell,  in  discussing  the  same  condition,  has  the  following 
to  say:  "The  danger  is  practically  eliminated  by  the  use  of  local  anes- 
thesia, and  at  the  same  time  the  necessity  for  a  hurried  operation  is 
practically  done  away  with.  The  knowledge  that  a  cocain  explora- 
tion is  without  danger  must  lead  one  to  explore,  without  hesitation, 
many  cases  where  a  positive  diagnosis  would  be  demanded  before  sub- 
jecting these  patients  to  a  general  narcosis.  Typhoid  patients,  as  a 
rule,  are  ideal  subjects  for  local  anesthesia." 

It  will  be  seen  after  a  study  of  the  above  that  the  clinical  test  on 
the  human  subject  agrees  rather  with  the  findings  of  Lennander  than 
with  those  of  the  animal  experimenters,  but  without  discrediting  the 
value  of  the  latter.  What  effect  in  man  the  anesthetic  solution,  in- 
filtrated in  the  abdominal  wall,  has  upon  the  sensibility  of  the  intra- 
abdominal  organs  through  its  central  action  must  indeed  be  very 
slight,  if  any,  and,  at  least  for  the  present,  has  not  been  demonstrated 
in  man.  It  will  also  be  seen  from  the  range  of  operations  mentioned 
that  the  abdominal  cavity  is  in  many  ways  a  free  field  for  exploration 
under  local  anesthesia,  which  is  often  limited  as  much  by  skill,  dex- 
terity, and  gentleness  of  the  operator  as  well  as  by  the  fundamental 
principles  and  limitations  already  laid  down. 

Lipectomy. — This  operation  is  quite  easily,  quickly,  and  satis- 
factorily performed  under  local  anesthesia.  The  procedure,  however, 
is  more  often  done  as  a  final  step  following  laparotomy,  hernia,  or 
other  abdominal  operations  performed  under  general  anesthesia. 
Many  stout  people  seek  relief  for  excessive  abdominal  fat  who  are  in 
apparently  good  health,  but  to  whom  one  may  hesitate  to  administer 
a  general  anesthetic  owing  to  their  excessive  obesity;  in  these  the 
operation  is  particularly  inviting  under  local  anesthesia,  and  becomes 
more  -so  in  the  presence  of  any  organic  lesion. 

The  length  of  the  incision  and  mass  of  tissue  to  be  removed  may, 
in  the  minds  of  the  uninitiated,  preclude  the  possibility  of  its  being 
satisfactorily  done  under  purely  local  methods;  this,  however,  is  not 
the  case. 

The  procedure  should  be  undertaken  as  follows :  Select  any  point 
along  the  proposed  line  of  incision,  and  with  the  small  hypodermic 
syringe  produce  an  intradermal  wheal,  using  solution  No.  i  (0.25  per 
cent,  novocain  with  2  or  3  drops  of  adrenalin  to  the  ounce)  then  with 
the  large  10  c.c.  syringe  and  long  fine  needle  enter  at  this  point,  di- 
recting it  subcutaneously  along  the  line  of  the  proposed  incision,  in- 
jecting the  solution  as  the  needle  is  advanced;  another  introdermal 
wheal  is  now  made,  just  over  the  point  where  the  long  needle  stopped; 


356  LOCAL   ANESTHESIA 

the  long  needle  is  inserted  at  this  point  and  continued  as  before  (Fig. 
79).  The  above  is  repeated  until  the  entire  circumference  of  the 
mass  to  be  removed  has  been  infiltrated  along  the  proposed  line  of 
incision.  (See  illustrations  in  chapter  on  Principles  of  Technic;  also 
Hackenbuch,  Plan  of  Anesthesia,  same  chapter.)  Having  completed 
the  above  the  long  needle  is  now  directed  down  into  the  depths  of  the 
mass,  at  almost  right  angles  to  the  surface,  through  the  line  of  infil- 
tration, and  the  depths  of  the  mass  freely  infiltrated,  inserting  the 
needle  at  intervals  of  every  few  inches.  Fat  itself  has  no  sensation, 


Fig.  79. — Line  of  cutaneous  anesthesia  and  points  for  making  deep  injections  down  to 
abdominal  muscles  for  lipectomy. 

but  many  nerves  come  through  the  mass  on  their  way  to  the  skin, 
and  these  should  be  blocked  by  this  deep  infiltration.  As  the  fatty 
layers  are  divided  these  nerves  can  often  be  seen  in  the  glistening 
mass  before  they  are  cut,  and  should  receive  additional  injections  if 
any  question  exists  regarding  the  thoroughness  of  the  infiltration. 

These  nerves  often  accompany  blood-vessels,  which  aids  in  their 
ready  recognition.  Blood-vessels,  except  the  smallest,  when  un- 
accompanied by  demonstrable  nerves  should  also  be  blocked,  as 
nerve-fibers  exist  in  their  sheaths  and  walls. 

Large  amounts  of  solution  are  often  needed  for  the  removal  of  the 


THE   ABDOMEN  357 

fatty  masses,  and  for  this  reason  the  content  of  adrenalin  should  be 
somewhat  reduced  from  that  usually  employed  for  smaller  operations, 
2  or  3  drops  to  the  ounce  being  sufficient. 

The  possibility  of  such  low-grade  tissue  as  fat  suppurating  follow- 
ing its  infiltration,  as  in  the  above  operation,  has  been  advanced  by 
some  as  an  objection  to  its  use;  this,  however,  I  have  not  found  to  be 
the  case  in  my  hands. 

The  following  case  illustrates  the  possibilities  in  this  direction: 

Mrs.  L.,  rather  short,  middle-aged  woman,  weighing  285  pounds,  with  cardiac  and 
renal  lesions.  For  many  years  the  abdominal  fat  had  been  accumulating,  until  for  some 
time  prior  to  operation  a  large  fatty  fold  hung  from  the  abdomen  over  the  pubes,  pro- 
ducing an  unsightly  appearance,  seriously  interfering  with  her  movements  and  comfort. 
She  had  long  sought  relief,  but  being  an  unfavorable  surgical  subject  had  been  refused 
operation. 


Fig.  80. — Fatty  mass :  weight,  13^  pounds,  29  inches  long,  14  inches  wide, 
inches  thick,  removed  under  local  anesthesia. 

She  was  operated  on  June  16,  1913,  by  the  method  outlined  above  and  a  mass  of  fat, 
weighing  13%  pounds,  29  inches  long  and  14  inches  wide  by  4)^  inches  thick,  was 
removed.  One  quart  of  0.25  per  cent,  novocain  solution  being  required  for  the  pro- 
cedure no  pain  or  shock  was  experienced  by  the  patient.  Recovery,  except  for  some 
gastro-intestinal  disturbance,  was  free  from  incident,  the  wound  healing  very  satis- 
factorily. Specimen  shown  in  Fig.  80. 

As  a  final  proposition,  it  may  be  stated  that  where  the  intra-ab- 
dominal  condition  presents  inflammation  with  adhesions  that  a  resort 
may  be  had  to  the  paravertebral  method  of  anesthesia  discussed 
under  this  heading;  or,  where  it  is  desirable  to  lessen  or  reduce  to  a 
minimum  the  general  anesthetic,  the  abdomen  can  first  be  opened  by 
local  anesthesia,  determining  just  what  is  to  be  done,  resort  may  then 


358  LOCAL   ANESTHESIA 

be  had  to  light  general  anesthesia,  combining  infiltration  of  the  region 
operated  upon  to  block  all  afferent  nerves  preventing  shock  or  other 
reflexes,  as  discussed  in  the  chapter  on  Anoci-association. 

Many  procedures  not  discussed  in  these  pages  may  be  carried  out 
by  an  application  of  the  principles  laid  down  in  the  general  remarks 
on  this  subject. 


CHAPTER  XVIII 
HERNIA 

"ONE  of  the  most  notable  benefits  that  surgery  has  derived  from 
the  introduction  of  cocain  has  been  the  successful  local  anesthesia 
of  the  hernial  regions,  notably  the  inguinal  region. 

"One  of  the  earliest  applications  of  local  anesthesia  by  the  use  of 
cocain  for  the  relief  of  strangulated  hernia  was  made  by  an  American 
surgeon  (Hewlett,  1887).  Since  that  time  the  reports  from  German, 
French,  Italian,  and  American  clinics  have  so  steadily  increased  that 
it  would  be  difficult  to  even  mention  the  names  of  the  operators  with- 
out the  risk  of  serious  omission. 

"It  would  be  difficult  to  trace  the  history  of  cocain  to  its  first  ap- 
plication in  the  radical  cure  of  hernia,  but  it  is  evident  that  many 
operators  in  this  country  and  Europe  began  to  resort  to  this  mode  of 
practice  even  in  the  early  days  of  cocain  technic.  Reclus,  in  his 
book  on  'Cocain  in  Surgery'  (1895),  describes  his  method  of  infiltra- 
tion (with  i  per  cent,  solution)  for  the  cure  of  hernia,  which  he  has 
performed  as  a  typical  procedure  many  times.  Ceci,  of  Pisa,  in  a 
contribution  l/Semaine  Medicale,'  Paris,  as  early  as  1899,  vol.  xix,  p. 
41),  states  that  by  combining  the  statistics  of  his  clinics  in  Genoa  and 
Pisa  (1885-1899)  he  had  collected  543  radical  operations  for  hernia, 
of  which  363  were  anesthetized  with  cocain  alone.  Ceci  made  use  of 
a  5  per  cent,  cocain  prepared  with  3  per  cent,  boric  acid  solution. 
He  believed  in  deep  infiltrations,  including  the  hypoderm  and  the 
subaponeurotic  layers  in  his  primary  injections,  without  reference  to 
a  separate  analgesia  of  individual  nerves  of  the  region.  The  large 
number  of  personal  observations  reported  by  Ceci  alone  indicate  that, 
up  to  1899,  great  success  had  already  been  attained  in.  the  radical  cure 
of  hernia  by  the  earlier  methods  of  direct  local  infiltration"  (Matas). 

Since  these  early  days  these  contributions  have  been  too  numerous 
to  mention,  and  the  performance  of  this  operation  under  local  anes- 
thesia is  now  no  longer  a  novelty. 

The  value  of  the  neuroregional  method  had  not  been  tested  in 
this  operation  until  1897,  and  it  remained  for  Dr.  Harvey  Gushing, 
of  Johns  Hopkins  University  (Prof.  Halsted's  Clinic),  to  do  so. 

And  again,  in  1900,  in  the  "Annals  of  Surgery,"  he  thoroughly 

359 


360  LOCAL  ANESTHESIA 

discusses  this  method,  which  has  been  tried  and  accepted  the  world 
over  by  all  who  resort  to  local  anesthesia  for  this  operation. 

INGUINAL  HERNIA 

With  the  general  improvement  in  local  anesthesia  and  the  logical 
advancement  in  the  technic  as  applied  to  any  one  operation,  the  re- 
sult of  time  and  experience,  this  operation  under  local  anesthesia  has 
become  quite  commonplace  and  is  often  the  first  major  procedure 
attempted  by  the  beginner  in  this  field  of  work. 

There  is  probably  no  commonly  performed  major  operation  that 
is  more  inviting  to  local  or  regional  methods  of  anesthesia  than  in- 
guinal herniotomy.  This  is  so  on  account  of  the  superficial  position 
of  the  parts,  the  anatomic  arrangement,  and  the  course  and  distribu- 
tion of  the  nerves  involved. 

Such  operations  under  local  methods  require  a  thorough  knowl- 
edge of  anatomy;  often  a  more  accurate  knowledge  than  is  required 
for  the  same  operations  under  general  anesthesia.  It,  above  all, 
makes  of  us  nerve  anatomists,  and  forces  us  to  respect  and  preserve 
from  injury  all  nerves  encountered.  While  during  the  operation  we 
are  principally  concerned  with  the  sensory  functions  of  the  nerves, 
we  must  not  lose  sight  of  the  fact  that  most  nerves  are  motor  and 
trophic,  as  well  as  sensory. 

Division  of  an  important  nerve  may  be  followed  by  muscular 
atony  and  relaxation  of  the  parts,  and,  in  the  case  of  herniotomy,  be 
followed  by  a  recurrence  of  the  trouble  or  an  unpleasant  sagging  of 
the  scrotum  in  case  the  cremaster  muscle  is  paralyzed  by  division  of 
the  genital  branch  of  the  genitocrural,  or  a  possible  atrophy  of  the 
testicle.  Of  course,  such  injuries  should  not  occur  in  the  hands  of 
careful  operators  even  under  general  anesthesia,  but  under  local  anes- 
thesia there  are  greater  precautions  taken,  as  we  are  forced  to  recog- 
nize and  respect  each  individual  nerve. 

One  of  the  many  advantages  of  local  over  general  anesthesia,  as 
mentioned  elsewhere,  is  particularly  emphasized  here  in  the  absence 
of  vomiting;  these  efforts,  if  prolonged  or  severe,  may  compromise 
the  results  of  the  operation  by  loosening  sutures  and  favor  a  recur- 
rence of  the  trouble.  This  is  particularly  likely  to  be  the  case  in  large 
or  complicated  herniae,  where  often  extensive  plastic  resections  are 
necessary  to  secure  a  satisfactory  closure.  For  this,  if  for  no  other 
reason,  should  the  local  method  be  preferred,  and  I  believe  that  a 
comparison  of  statistics  will  show  a  lesser  percentage  of  recurrences 
following  closure  in  this  way. 


HERNIA  361 

The  size  of  the  hernia  is  no  centra-indication  for  this  method,  nor 
is  the  age  of  the  patient,  providing  he  is  enjoying  fairly  good  health; 
in  fact,  old  age  is  particularly  favorable  to  all  local  anesthetic  pro- 
cedures. Many  of  these  old  subjects  may  be  refused  operation  by 
general  anesthesia,  when  they  can  be  safely  and  easily  operated  upon 
by  this  method.  It  is  advisable  that  these  old  patients  should  be 
put  to  bed  for  a  day  or  two  before  operation  to  see  how  they  stand 
confinement,  and  to  enable  them  to  learn  to  empty  their  bladder  and 
bowels  in  the  recumbent  position. 

Another  important  consideration  which  applies  to  all  cases,  but 
more  particularly  to  the  aged,  is  that  nutrition  is  not  interfered  with, 
as  there  is  no  disturbance  of  the  gastro-intestinal  tract.  A  light  meal 
is  always  preferred  just  before  operation,  but  nourishment  should  be 
restricted  to  liquids  after  operation,  excluding  milk  for  the  first  day  or 
two.  If  the  subject  is  very  feeble,  stimulating  drinks,  such  as  coffee, 
toddy,  or  hot  tea,  may  be  administered  during  the  progress  of  the 
operation.  By  handling  feeble  and  aged  subjects  in  this  way — by 
local  anesthesia- — many  can  be  safely  carried  through  an  operation 
for  hernia  without  any  operative  or  postoperative  disturbance  what- 
ever, who  would  most  probably  succumb,  if  not  to  the  operation,  at 
least  to  the  necessary  postoperative  disturbances  following  general 
anesthesia. 

Nerves. — There  are  three  nerves  with  which  we  are  principally 
concerned  in  inguinal  hernia — the  iliohypogastric,  ilio-inguinal,  and 
genitocrural. 

The  skin  over  this  region  receives  branches  from  several  of  the 
surrounding  nerves,  especially  the  last  dorsal,  but,  as  it  is  infiltrated 
directly,  these  do  not  especially  interest  us  (Figs.  81,  82). 

The  ilio  hypo  gastric  nerve  perforates  the  transversalis  muscle  at 
its  posterior  part,  near  the  crest  of  the  ilium,  and  gives  off  its  iliac 
branch,  which  descends;  the  hypogastric  branch  continues  forward 
between  the  transversalis  and  internal  oblique,  perforating  the  in- 
ternal oblique  just  above  and  a  little  to  the  outer  side  of  the  internal 
ring.  It  then  runs  transversely  inward  toward  the  middle  line  on  the 
surface  of  the  internal  oblique,  and  just  above  and  a  little  to  the  outer 
side  of  the  external  ring  pierces  the  aponeurosis  of  the  external  ob- 
lique, and  is  distributed  to  the  skin  of  the  hypogastric  region. 

The  ilio-inguinal  nerve  appears  in  the  field  after  perforating  the 
internal  oblique  at  or  near  the  internal  ring  and  descends  along  the 
lower  part  of  the  inguinal  canal;  some  of  its  fibers  escape  through 
the  external  ring  at  its  outer  edge  and  curve  upward  and  outward 


362 


LOCAL  ANESTHESIA 


First  rib 


Pleura— 


Anterior  cutaneous 
branch,  second 
intercostal 


Lateral  cutane- 
ous branches,, 
fourth  inter- 
costal 


Muscular 
branches 

Cutaneous  branches,    - 
iliohypogastric 


L  Internal  oblique 

muscle 
Anterior  cutaneous 

branches,  twelfth 

intercostal 


Inguinal  ring 


Fig.  81. — Course  and  distribution  of  the  intercostal  nerves.     (After  Spalteholz.)     The 
intercostal  and  oblique  abdominal  muscles  are  removed.     (From  Braun.) 


HERNIA 


363 


to  the  subcutaneous  tissue  in  this  region.  Other  fibers,  which  follow 
the  cord  through  the  ring,  are  supplied  to  the  upper  portion  and  side 
of  the  scrotum  and  thigh.  This  nerve  is  not  constant,  and  occa- 
sionally is  found  joined  to  the  genital  branch  of  the  genitocrural  to 
form  the  external  spermatic  nerve,  or  it  may  form  a  common  trunk 
with  the  iliohypogastric. 


anterior  cutarfs^tt.da 


anterior  cutarfs  of  L 
(ilio-hypoof.) 


••Lateral  cut.o/ 12.  <L 
—Ant.  sup. spine 
••tat.cut.o/11 


Intern,  ring""" 
Exf.  ring' 


Fig.  82. — Sites  for  local  anesthesia  in  the  inguinal  region.     (After  Gushing.) 

The  genitocrural  nerve,  its  genital  branch,  appears  at  the  internal 
ring  and  passes  down  the  back  part  of  the  spermatic  cord  into  the 
scrotum,  where  it  supplies  the  cremaster  muscle,  testicle,  and  other 
contents  of  the  scrotum.  The  skin  of  the  scrotum  receives  fibers 
from  the  inferior  pudendal  branch  of  the  small  sciatic  and  from  the 


364 


LOCAL   ANESTHESIA 


superficial  perineal  branch  of  the  pudic,  in  addition  to  the  ilio-in- 
guinal  nerve  already  mentioned. 

It  will  be  seen  from  a  study  of  the  above  that  after  the  skin  is 
passed  all  nerves  entering  the  field  emerge  at  or  near  the  internal  ring, 
and  it  is  consequently  here  that  we  inject  most  of  our  solutions. 

Preparation  for  the  Operation. — Preliminary  hypodermic  pan- 
topon  or  morphin,  %  gr.,  with  scopolamin,  ^50  gr.,  one  hour  be- 
forehand. 

Four  ounces  of  solution  No.  i  (novocain,  0.25  per  cent.;  sodium 
chlorid,  0.4  per  cent.),  to  which  add  15  drops  of  adrenalin  solution 
(i :  1000).  If  the  hernia  is  very  large,  it  is  well  to  have  on  hand  more 


Fig.  83. — Long  needle  passed  through  intradermal  station  to  reach  position  of  iliohypo- 
gastric  nerve  beneath  tendon  of  external  oblique. 

than  the  4  ounces.  Small  hernias  may  not  require  this  much,  but 
it  is  well  to  have  an  ample  supply. 

Two  small  hypodermic  syringes  and  one  large  10  c.c.  syringe, 
with  long  fine  needles,  or  a  Matas'  infiltration  apparatus — all  well 
tested  beforehand  to  be  sure  they  are  in  good  working  order. 

Some  operators  prefer  to  inject  the  cases  about  fifteen  minutes 
to  one-half  hour  beforehand,  and  allow  them  to  wait  for  the  solution 
to  diffuse  and  become  fixed  in  the  tissues.  This  practice,  while  ad- 
visable elsewhere,  we  do  not  find  necessary  here,  and  proceed  at  once 
with  the  operation.  Also  some  prefer  to  use  a  i  per  cent,  novocain 
solution  to  infiltrate  the  nerves  as  they  are  encountered,  but,  as  all 


HERNIA 


365 


the  nerves  concerned  are  very  small,  it  is  unnecessary  to  use  any  but 
the  ordinary  infiltration  solution  (No.  i). 

Begin  the  injection  with  the  small  hypodermic  syringe  at  the 
highest  point  of  the  proposed  incision,  at  the  upper  and  outer  part  of 
the  field,  about  i^  inches  internal  and  slightly  below  the  anterior 
spine  of  ilium.  Make  the  injection  intradermally.  With  the  large 
syringe  and  long  needle  enter  through  this  wheal  directing  the  needle 
downward,  injecting  as  it  is  advanced  and  distribute  about  2  drams 
of  solution  in  the  subcutaneous  tissues  at  this  point  (Fig.  83).  By 
advancing  the  needle  slightly  further  through  the  subcutaneous  tis- 


Fig.  84. — Needle  is  partially  withdrawn  from  position  shown  in  Fig.  83  and  directed 
subcutaneously  toward  pubes. 

sues  the  aponeurosis  of  the  external  oblique  is  reached;  this  is  recog- 
nized as  the  first  plane  of  resistance  which  the  needle  encounters 
after  the  skin  is  passed  and  varies  in  depth  according  to  the  stoutness 
of  the  individual.  The  aponeurosis  is  gently  pierced  at  this  point 
and  about  2  drams  of  solution  deposited  beneath  it.  This  is  the  first 
point  at  which  the  iliohypogastric  nerve  is  encountered  and  in  its 
normal  position  will  not  be  found  to  be  y±  inch  from  the  needle  point. 
The  needle  is  now  slightly  withdrawn  into  the  subcutaneous  tissues 
and  its  point  directed  toward  the  spine  of  the  pubis  injecting  as  the 
needle  is  advanced  the  entire  distance  (Fig.  84),  distributing  in  all 
about  3^2  ounce  of  solution. 


366 


LOCAL   ANESTHESIA 


The  long  needle  is  now  withdrawn  and  beginning  at  the  primary 
wheal  in  the  skin  this  tissue  is  infiltrated  intradermally  as  far  down 
as  the  spine  of  the  pubis  along  the  proposed  line  of  incision,  which 
may  now  be  made.  The  idea  in  making  some  of  the  deeper  injections 
first  is  to  allow  them  ample  time  to  diffuse  and  thoroughly  saturate 
all  nerve-fibers  in  their  neighborhood.  The  first  incision  is  made 
through  the  skin  the  entire  length  of  the  field  but  carried  down 
through  the  subcutaneous  tissue  only  in  the  upper  part  of  the  field 
where  the  aponeurosis  of  the  external  oblique  is  exposed.  •  The  long 
needle  is  now  used  and  entered  at  this  point,  near  where  it  first 


Fig.  85. — i,  Iliohypogastric  nerve;  2,  ilio-inguinal  nerve;  3,  spermatic  cord;  4,  hernial 
sac  dissected  free.  The  genitocrural  nerve  is  not  seen,  as  it  lies  within  the  cord  on 
its  posterior  aspect, 

pierced  the  aponeurosis  to  reach  the  iliohypogastric  nerve,  and 
passed  downward  beneath  the  aponeurosis  to  Poupart's  ligament, 
reaching  this  point  about  midway  between  the  anterior-superior 
spine  of  the  ilium  and  the  pubis;  here  the  ilio-inguinal  nerve  will  be 
found  in  the  inguinal  canal  below  the  cord.  A  finger  held  over  the 
skin  can  guide  the  progress  of  the  needle;  about  2  drams  of  solution 
are  deposited  along  the  course  of  the  needle  and  at  this  point. 

The  course  of  the  needle  is  now  directed  slightly  inward  but  still 
close  under  the  aponeurosis  and  a  little  additional  solution  deposited 
on  each  side  of  the  external  ring  which  can  now  be  readily  identified 


HERNIA .  367 

by  palpation  through  the  subcutaneous  tissues.  We  can  now  freely 
expose  the  aponeurosis  throughout  its  entire  extent  by  dividing  the 
remaining  subcutaneous  tissue.  I  usually  stop  here  to  ligate  the 
superficial  vessels,  clearing  the  field  of  forceps,  thus  allowing  the  last 
made  injections  a  little  time  to  work.  The  aponeurosis  of  the  ex- 
ternal oblique  is  now  divided  and  its  edges  retracted;  this  exposes 
the  cord  and  hernia  sac  lying  on  top,  the  whole  surrounded  by  the 
cremasteric  fascia  through  which  run  bundles  of  the  cremasteric  mus- 
cle. This  is  opened  above  or  on  its  outer  side  and  the  two  edges  re- 
tracted, freely  exposing  the  cord  and  sac;  by  rolling  the  sac  and  over- 
lying tissues  inward  the  cord  is  more  plainly  brought  into  view  and 
its  component  parts  recognized.  With  a  small  syringe  and  fine 
needle  the  cellular  tissue  of  the  cord  is  injected  at  several  points 
gently  feeling  the  way  high  up  toward  the  internal  ring.  The  genito- 
crural  nerve  which  lies  at  the  back  of  the  sac  may  be  identified,  but 
this  is  unnecessary  as  it  is  amply  reached  by  the  surrounding  injec- 
tions. The  cord  is  now  left  and  the  inner  edge  of  the  cremasteric 
fascia  retracted  inward  exposing  the  neck  of  the  sac  where  it  comes 
from  under  the  edge  of  the  conjoined  tendon.  The  sac  at  this  point 
is  surrounded  by  the  transversalis  or  retro-peritoneal  fascia  which 
varies  greatly  in  amount  in  different  individuals,  if  thin  the  perito- 
neum of  the  sac  which  underlies  it  can  be  easily  reached  by  the  solu- 
tion injected  here;  this  is  done  circumferentially  at  the  proximal 
point  where  the  sac  comes  off  from  the  parietal  peritoneum  raising 
the  sac  to  get  to  the  under  surface.  In  the  ordinary  case,  which  is 
handled  this  way,  this  completes  the  anesthesia  and  the  operation 
can  proceed  absolutely  without  any  pain  and  by  any  method  pre- 
ferred by  the  operator. 

An  existing  varicocele  or  any  other  complication  should  be  dealt 
with  now  and  requires  no  further  infiltration.  The  testicle  may  also 
be  exposed  and  handled  if  necessary.  It  should  be  borne  in  mind, 
however,  that  any  undue  traction  upon  the  cord  by  pulling  upon  the 
parts  within  the  cavity  will  cause  pain,  but  none  is  otherwise  ex- 
perienced. The  neck  of  the  sac  can  now  be  closed — by  crushing, 
if  large,  and  ligated;  or  sutured,  if  preferred. 

If  the  above  technic  is  followed  absolutely  no  pain  should  be  felt 
by  the  patient;  where  pain  is  inflicted  the  technic  is  at  fault.  In  the 
hands  of  a  skilful  operator  an  ordinary  hernia  can  be  closed  by  using 
not  over  3  ounces  of  solution  (we  often  use  much  less),  and  the  time 
consumed  is  not  over  five  or  ten  minutes  longer  than  would  have 
been  required  with  general  anesthesia. 


368 


LOCAL  ANESTHESIA 


Fig.  86. — Method  of  making  injections  around  neck  of  sac,  with  finger  within  sac. 


Fig.  87. — Semi-diagramatic  drawing  from  actual  operation  illustrating  inguinal 
canal  opened,  sac  dissected  from  cord  and  opened,  and  separate  fatty  mass  extending 
down  into  internal  ring.  (Modified  from  Speed.) 


HERNIA  369 

In  case  the  hernial  ring  is  very  large,  it  may  be  necessary  to  loosen 
the  internal  oblique  and  transversalis  from  the  edge  of  the  rectus  so  as 
to  enable  the  conjoined  tendon  to  be  brought  down;  in  case  this  is 
necessary,  and  the  dissection  be  carried  very  high,  some  additional 
infiltration  at  this  point  may  be  needed,  and  should  be  made  directly 
into  the  tissues  to  be  dissected. 

In  case  the  sac  is  large  and  thick,  or  there  is  much  retroperitoneal 
tissue  around  it,  it  is  preferable  to  open  it  some  distance  from  the 
ring  after  first  infiltrating  the  point  of  incision,  a  finger  can  then  be 
passed  up  its  lumen  toward  the  ring  and  the  neck  of  the  sac  injected 
circumferentially  with  the  finger  held  in  this  position  by  passing  the 
needle  through  the  walls  of  the  sac  down  toward  the  finger  (Fig.  86) . 
Or,  if  preferred,  the  sac  can  be  more  freely  opened  and  injected  from 
within  as  shown  in  Fig.  87. 

In  case  the  sac  contain  intestines  or  omentum,  these  should  be 
replaced  if  possible  by  manipulation  before  opening  the  sac.  If  this 
cannot  be  done,  the  neck  of  the  sac  should  be  blocked  as  thoroughly 
as  possible  before  opening.  It  should  always  be  borne  in  mind  that 
the  sac  is  formed  by  the  parietal  peritoneum  which  is  very 
sensitive. 

After  the  neck  of  the  sac  has  been  well  blocked  and  the  sac  opened 
the  pushing  of  the  contents  through  the  ring  will  cause  no  pain  but 
should  be  gently  done.  In  case  the  omentum  or  intestines  are  ad- 
herent to  the  sac  wall  their  separation  causes  no  pain  after  the  neck 
of  the  sac  has  been  blocked,  but  if  much  mesentery  accompanies 
the  intestine,  this  is  always  sensitive  and  should  be  well  injected 
proximally  where  it  comes  through  the  internal  ring  before  extensive 
manipulations  are  resorted  to.  In  making  these  injections  much 
care  is  sometimes  necessary  not  to  injure  the  many  vessels  which  are 
often  quite  congested  as  a  result  of  the  constriction.  If  the  omentum 
is  found  hard  and  fibrous  from  its  long  sojourn  in  the  sac  it  will  re- 
quire resection,  but,  unless  badly  damaged,  it  should  not  be  sacri- 
ficed, as  it  is  an  organ  of  many  valuable  functions. 

The  exposure  of  the  omentum  never  gives  rise  to  any  discomfort, 
and  its  resection  causes  no  complaint,  as  it  has  no  sensation;  but 
large  vessels  within  it  are  sensitive,  and  should  first  be  blocked  before 
ligation  or  division. 

In  the  case  of  very  large  hernias,  where  it  is  necessary  to  carry 
the  skin  incision  well  down  over  the  scrotum,  the  skin  must  be  infil- 
trated all  the  way. 

The  following  histories  may  prove  interesting: 

24 


370  LOCAL   ANESTHESIA 

Floyd,  aged  seventy-five,  Ward  9,  an  old  and  feeble  man.  Entered  the  service  for 
the  removal  of  epithelioma  of  right  temporal  region,  and  while  convalescing  from  the 
operation,  which  was  done  with  local  anesthesia,  a  large  inguinal  hernia  of  the  left  side, 
of  fifteen  years'  duration,  became  incarcerated  and  irreducible.  He  was  operated  on 
June  26,  1908,  by  the  method  described  above,  and  was  discharged  cured  in  two  weeks, 
with  no  recurrence  since.  This  was  a  particularly  satisfactory  case,  in  view  of  the  ex- 
treme feebleness  of  the  patient. 

Pear,  aged  sixty-four  (Fig.  88).  Left  inguinal  hernia  of  thirty-four  years'  duration 
with  enormous  sac,  extending  to  near  the  knee.  The  contents  of  the  sac  had  not  been 
reduced  for  years;  the  photograph  gives  a  good  idea  of  the  condition.  The  inguinal 
ring  was  large  enough  to  admit  three  fingers.  In  view  of  marked  arteriosclerosis,  with 
renal  and  cardiac  lesions,  the  operation  was  performed  by  the  above-mentioned  method 


Fig.  88. — Large  irreducible  hernia  operated  on  by  author  under  local  anesthesia.     Sac 
contained  omentum  and  intestines;  large  part  of  omentum  was  resected. 

on  August  27,  1908.  A  large  part  of  the  omentum  was  adherent  to  the  sac  and  much 
thickened  and  had  to  be  resected.  A  portion  of  the  rectus  muscle  was  transplanted  to 
close  the  inguinal  opening.  Some  of  the  redundant  skin  of  the  parts  was  resected.  The 
operation  was  entirely  painless,  with  union  by  first  intention,  and  the  patient  was  up  in 
two  weeks.  This  case  was  a  bad  hernia  and  a  severe  test  of  the  method,  and  clearly  de- 
monstrated its  usefulness  and  feasibility  in  these  cases.  I  have  recently  seen  the  case, 
and  he  had  remained  well,  with  no  sign  of  recurrence. 

In  strangulated  hernia,  general  anesthesia  is  contra-indicated,  and 
should  rarely,  if  ever,  be  used.  In  very  severe  and  prostrated  cases 
the  general  anesthetic  may  add  sufficient  additional  depression  to 
cause  a  fatal  issue.  The  sac  should  here  be  exposed  and  opened 
under  infiltration.  If  the  patient  is  very  weak  a  radical  operation 


HERNIA  371 

should  not  be  attempted  at  the  time,  but  the  bowel,  if  gangrenous, 
opened  and  drainage  permitted.  It  will  here  frequently  be  found 
that  the  bowel  is  adherent  around  the  ring  and  the  general  cavity 
walled  off.  If  this  is  not  the  case,  a  few  sutures  and  packing  may  be 
resorted  to  to  close  off  the  cavity  and  the  bowel  at  once  opened. 
The  improvement  permitted  by  this  procedure  revives  the  patient 
and,  after  all  gangrenous  material  has  come  away,  the  ends  of  the 
bowel  can  be  approximated  by  the  Murphy  button  or  suture. 

We  then  wait  for  good  union  to  take  place  and  the  wound  to  be- 
come clean  and  covered  with  healthy  granulation,  when  it  may  be 
closed  with  a  small  drain.  The  following  case  illustrates  this  type: 

Mr.  S.,  aged  seventy-two.  Had  had  a  large  inguinal  hernia  since  he  was  seventeen. 
It  had  frequently  become  incarcerated,  but  he  was  always  able  to  reduce  it  until  a  few 
days  prior  to  my  seeing  him,  when  it  again  became  incarcerated  and  all  efforts  at  reduc- 
tion failed,  strangulation  following.  Patient  was  very  feeble,  pulse  almost  impercepti- 
ble, temperature  subnormal  with  cold  extremities,  and  almost  constant  stercoraceous 
vomiting.  Under  local  anesthesia  the  sac  was  opened.  The  bowel  and  fat  attached  to 
it  were  found  gangrenous,  with  a  large  quantity  of  foul  fluid  in  the  sac.  The  neck  of  the 
sac  was  securely  protected  with  sutures,  packs  and  rubber  tissue,  the  gangrenous  fat 
cut  away,  and  the  loop  of  bowel  opened  at  the  distal  end.  The  patient  revived  at  once, 
all  vomiting  ceasing,  next  day  was  in  a  rolling  chair  on  the  gallery,  and  in  a  few  days 
was  sitting  up. 

Nourishment  had  been  at  once  resumed,  and  his  improvement  was  noticeable  daily. 
In  ten  days  the  bowel  was  closed  by  suture,  and  two  weeks  later  the  wound,  now  being 
quite  healthy,  closure  under  local  anesthesia  was  performed.  The  bowel,  freed  from 
the  old  sac,  dropped  back  into  the  cavity,  the  wound  enlarged  until  the  anatomy  became 
apparent,  and  the  parts  then  closed  with  two  rubber-tissue  drains,  one  within  the  cavity 
and  one  subcutaneously.  The  Fowler  position  was  used  for  twenty-four  hours,  then  dis- 
continued, and  the  drain  removed  in  three  or  four  days.  Recovery  was  without  inci- 
dent, the  patient  being  discharged  about  three  weeks  later.  This  illustrates  a  type  of 
case  which,  I  believe,  if  handled  any  other  way  would  have  resulted  fatally. 

Reclus  very  justly  refers  to  operations  for  strangulated  hernia  as 
"the  triumph  of  cocain."  In  strangulation  it  is  the  anesthetic  of  elec- 
tion, and  it  is  only  in  special  conditions,  such  as  in  herniae  of  unu- 
sually large  size,  with  eventration  of  the  abdominal  contents  and 
when  extensive  adhesions  exist,  that  he  would  prefer  a  general  anes- 
thetic. In  advanced  strangulations,  with  vomiting  of  intestinal  con- 
tents, the  dangers  of  septic  pneumonia  and  secondary  renal  compli- 
cations from  chloroform  and  ether  are  especially  to  be  feared,  and 
more  particularly  in  the  aged.  Then,  again,  colostomy  for  strangu- 
lation is  an  urgent  operation  which,  in  country  practice,  frequently 
compels  the  surgeon  to  depend  upon  unskilled  assistants.  Under 
these  circumstances  the  value  of  a  local  anesthetic  entirely  under 
the  control  of  the  operator  becomes  especially  apparent.  It  is  not 


372  LOCAL   ANESTHESIA 

surprising,  therefore,  that  Mehler  enthusiastically  asserts  that  he 
who  has  tried  local  anesthesia  in  these  conditions  will  never  feel  in- 
clined to  return  to  general  anesthesia,  unless  compelled  to  by  pres- 
sure of  unusual  circumstances. 

FEMORAL    HERNIA 

This  hernia,  except  in  very  fat  people,  is  easily  operated  upon 
with  local  anesthesia,  and  is  best  suited  to  the  infiltration  method. 
Regional  anesthesia  cannot  be  employed,  as  the  nerve-supply  is  from 
many  sources  and  reaches  the  field  from  several  directions,  all  being 
small  branches.  The  method  of  procedure  will  likely  vary,  accord- 


Fig.  89. — Line  of  cutaneous  anesthesia  for  femoral  hernia. 

ing  as  to  whether  or  not  the  patient  is  stout  or  thin,  and  whether  the 
hernial  sac  can  be  readily  defined  from  the  surrounding  tissues. 

In  stout  persons  or  in  poorly  defined  sacs  an  incision  had  best  be 
made  in  the  long  axis  of  the  tumor,  infiltrating  layer  after  layer,  and 
cutting  as  we  go  (Fig.  89).  After  the  sac  has  been  reached  and 
defined  the  tissues  at  its  sides  and  neck  can  be  infiltrated,  care  being 
taken  to  locate  and  avoid  the  femoral  vein  which  lies  just  to  its  outer 
side,  and,  on  account  of  the  sac  rising  forward,  often  a  little  behind. 
In  case  the  patient  is  thin  and  the  sac  well  defined  a  more  satisfactory 
plan  may  be  followed  by  making  a  circumferential  injection  around 
the  sac  subcutaneously;  or,  as  recommended  in  umbilical  hernia,  the 
sac  can  be  opened  early  in  the  operation  and  a  finger  passed  down 
within,  this  is  used  as  a  guide  to  the  needle  which  is  passed  down 
along  the  outer  wall  infiltrating  the  tissues  as  far  as  the  neck. 


HERNIA  373 

First  anesthetize  a  point  in  the  skin  near  the  edge  of  the  sac  with 
a  small  hypodermic  syringe.  If  the  Matas  infiltration  apparatus 
with  a  curved  needle  is  convenient,  it  will  be  found  very  useful  here ; 
if  not,  the  large  syringe  with  a  long  needle  will  answer.  The  advan- 
tage here  of  the  Matas  apparatus  with  the  curved  needle  is  that  the 
entire  circumference  of  the  sac,  unless  very  large,  can  be  reached  and 
infiltrated  from  a  single  point  of  puncture  of  the  skin;  if  a  straight 
needle  is  used  several  punctures  will  have  to  be  made. 

First  advance  the  needle  closely  under  the  skin,  then  through  the 
deeper  subcutaneous  tissues  in  all  directions  around  the  sac  on  the 
outer  side,  taking  care  not  to  penetrate  beneath  the  fascia  lata  for 
fear  of  injuring  the  femoral  vein,  but  on  the  inner  side  a  much  greater 
depth  can  be  penetrated  without  fear  of  injury. 

It  may  be  necessary  to  avoid  the  saphenous  vein  at  the  lower  por- 
tion. The  precaution  mentioned  elsewhere,  when  injecting  in  the 
neighborhood  of  large  veins,  should  here  be  observed,  of  injecting 
only  when  the  needle  is  being  advanced  or  withdrawn,  and  never 
when  the  point  is  stationary,  as  a  vein  may  be  entered  and  a  large 
quantity  of  the  solution  thrown  directly  into  the  circulation.  If  a 
vein  should  be  pierced  with  a  fine  needle  no  serious  consequences  will 
result. 

The  injection  by  the  above  method  is  made  very  quickly,  and 
all  nerves  entering  the  field  from  any  direction  are  bathed  in  the 
solution  and  anesthetized.  It  is  unnecessary  to  inject  the  skin  along 
the  proposed  line  of  incision  if  a  few  minutes'  delay  is  permitted  for 
the  solution  to  diffuse.  This  plan  of  Lennander,  of  waiting  fifteen 
to  twenty  minutes  after  the  injection  is  of  advantage  here.  But  in 
case  it  is  desirable  to  proceed  at  once,  and  the  skin  in  the  middle 
line  is  not  anesthetic,  it  can  be  infiltrated  intradermally  and  the 
incision  made  at  once,  as  the  deeper  parts  will  be  found  well  anes- 
thetized. 

Before  opening  the  hernial  sac  it  should  be  observed  whether  or 
not  it  is  the  bladder,  which  is  very  common  in  these  herniae,  and 
may  be  opened  in  looking  for  the  peritoneal  investment. 

The  neck  of  the  sac  is  freed  and  Gimbernat's  ligament  divided, 
when  reduction  is  usually  easy.  Closure  can  then  be  accomplished 
by  any  recognized  method,  after  first  anesthetizing  the  neck  of 
the  sac. 

In  case  it  is  preferred  the  inguinal  canal  can  be  opened  and  the 
sac  pulled  up  from  above.  If  this  method  is  adopted,  the  skin  and 
subcutaneous  tissues  along  the  course  of  the  inguinal  canal  should  be 


374  LOCAL   ANESTHESIA 

infiltrated  and  the  needle  passed  down  through  the  aponeurosis  of 
the  external  oblique  into  the  canal  and  about  %  ounce  of  solution 
deposited  at  several  points  here.  After  the  incision  has  been  made 
and  the  canal  opened,  the  parts  are  freely  retracted  exposing  the 
neck  of  the  sac  which  is  injected  quite  liberally  circumferentially. 
This  should  complete  the  necessary  anesthesia  for  small  hernias, 
but  in  case  the  sac  is  very  large  and  adherent  to  the  tissues  of  the 
thigh  some  peripheral  injections  may  have  to  be  made  around  it 
at  its  peripheral  parts  before  the  sac  can  be  freely  separated;  when 
necessary  these  can  be  made  by  passing  the  needle  through  the  wound 
over  Poupart's  ligament  into  the  tissues  around  the  sac.  The  sac 
can  be  dealt  with  and  the  wound  closed  by  any  method  preferred 
by  the  operator. 

The  solution  used  here  is  the  same  as  for  inguinal  hernia  (No.  i , 
novocain, 0.25  per  cent.;  sodium  chlorid,  0.4  per  cent.;  and  adrenalin, 
10  to  15  drops). 


In  very  fat  individuals  with  large  herniae  and  many  adhesions  and 
tense  abdominal  walls  this  operation  may  be  difficult  under  any 
method,  but  the  difficulties  are  much  less  under  local  anesthesia  and 
the  certainty  of  a  cure  greatly  increased. 

In  all  these  operations  the  mechanical  difficulties  are  very  much 
lessened  by  putting  the  patient  to  bed  for  a  few  days,  on  restricted 
diet,  with  daily  laxatives.  This  relaxes  the  abdominal  walls  and 
relieves  the  intra-abdominal  tension,  and  approximation  of  the  gap 
can  be  much  more  easily  obtained. 

With  Solution  No.  i  several  stations  in  the  skin  are  anesthetized: 
if  the  hernia  is  small,  one  on  each  side;  if  large,  one  above  and  one 
below,  in  the  median  line,  in  addition  (Figs.  90,  91).  By  entering  at 
these  points  (Matas'  infiltration  apparatus  or  large  syringe  with  long 
needle)  and  passing  the  needle  in  all  directions,  a  circumferential  in- 
jection is  made  into  all  the  subcutaneous  tissues,  thus  creating  a  zone 
of  anesthesia.  If  the  underlying  muscles  are  clearly  outlined,  and 
there  is  no  danger  of  going  through  them,  these  may  be  infiltrated 
at  the  same  time ;  otherwise  this  had  better  be  delayed  until  they  are 
exposed.  After  a  delay  of  a  few  minutes,  to  allow  the  solution 
time  to  diffuse,  the  incision  can  be  made.  First,  expose  the  muscles 
and  thoroughly  infiltrate  them  down  to  the  peritoneum,  if  this  has 
not  already  been  done.  While  we  are  waiting  for  the  last  injection 
to  diffuse,  bleeding  points  can  be  ligated  and  the  sac  opened  and  its 


HERNIA  375 

contents  dealt  with.  By  now  the  parietal  peritoneum  will  probably 
have  become  anesthetized,  and  the  sac  can  be  cut  away  around  the 
margin  of  the  gap;  if  the  peritoneum  is  still  sensitive,  a  long  needle 
is  passed  through  the  opening  into  the  subperitoneal  tissue  and  a 


Fig.  90. — Method  of  injection  around  umbilical  hernia.     (From  Braun.) 

moderate  injection  made  in  all  directions.     There  will  then  be  no 
further  sensation. 

In  dealing  with  the  contents  of  the  sac  omental  adhesions  cause 
no  trouble,  and  can  be  separated  or  divided  without  sensation.  If 
the  intestines  are  adherent  any  very  extensive  manipulation  may 


LOCAL  ANESTHESIA 

give  rise  to  cramps,  but  this  can  be  avoided  by  infiltrating  with  a 
fine  needle  the  points  of  adhesion,  care  being  taken  not  to  enter  the 
bowel. 

In  closing  these  herniae  the  Mayo  operation  of  overlapping  is 
usually  considered  the  best,  and  can  here  be  easily  done. 

It  may  often  be  found  advisable  to  open  the  sac  early  in  the 
operation  after  the  circumferential  injection  and  pass  a  finger  down 
through  the  ring;  this  is  held  under  the  edge  of  the  muscle  while  the 
long  needle  is  passed  down  from  without  through  the  tissues,  inject- 
ing the  several  planes  as  it  is  advanced  until  it  reaches  the  tissues 
just  above  the  palpating  finger  within  the  cavity.  In  this  way  the 


Fig.  91. — Cross-section  through  umbilical  hernia,  showing  method  of  making  deep  in- 
jections through  abdominal  walls.     (From  Braun.) 

injection  of  the  entire  field  is  made  before  the  operation  is  well 
advanced  without  danger  of  injuring  the  bowel  by  penetrating 
through  the  abdominal  walls,  and  will  often  be  found  the  more 
preferable  method  of  handling  these  cases.  The  same  procedure  is 
used  in  postoperative  herniae. 

POSTOPERATIVE  HERNIA 

In  selecting  these  herniae  for  operation  by  local  anesthesia  one 
should  be  guided  by  the  same  general  observations  made  regarding 
umbilical  hernia.  In  some  of  these  cases  the  gap  in  the  muscle  wall 
is  considerable,  often  ragged  and  irregular,  and  difficult  to  close  by 


HERNIA 


377 


general  anesthesia.  Under  local  anesthesia  these  difficulties  are  not 
increased,  but  often  lessened,  as  you  do  not  have  the  straining  so 
often  encountered  under  general  anesthesia.  The  patient  can  also 
better  take  a  position  favorable  to  relaxation  of  the  muscles,  but 
particularly  valuable  afterward  is  the  absence  of  vomiting,  which 
if  severe  or  protracted  may  often  jeopardize  the  results  of  the  work. 
It  is  here  often  highly  valuable  to  have  the  patient  remain  perfectly 
quiet  after  operation,  as  he  is  able  to  do  following  the  use  of  local 
anesthesia.  These  remarks  apply  equally  to  all  herniae. 


Fig.  92. — Method  of  making  crescentic  line  of  anesthesia  around  postappendicular 
hernia.     Deep  injections  made  through  heavy  dots. 

One  difficulty  encountered  in  postoperative  herniae  is  the  large 
amount  of  fibrous  tissue  encountered,  which  mats  all  the  structures 
together,  but  if  a  zone  of  anesthesia  is  created  just  outside  of  the 
area  no  special  difficulties  are  encountered. 

Herniae  in  the  midline  should  be  dealt  with  the  same  as  umbilical 
herniae,  by  a  complete  circumferential  injection  around  the  gap, 
thus  sequestering  all  nerve-endings  within  the  area. 

Herniae  just  to  either  side  of  the  midline  will  also  require  a  circum- 


378  LOCAL   ANESTHESIA 

ferential  injection,  as  the  nerve-fibers  from  the  other  side  lap  over  the 
midline  some  little  distance;  but  where  the  hernia  is  some  distance 
removed,  as  is  the  case  of  those  resulting  from  appendicular  opera- 
tions, a  circumferential  injection  is  not  necessary.  As  all  the  nerves 
in  the  anterior  abdominal  wall  proceed  downward  and  forward  be- 
tween the  muscle  planes,  it  is  only  necessary  to  make  the  injection 
in  such  a  way  as  to  block  these.  Consequently,  a  crescentic-like 
area  of  anesthesia  on  the  outer  side  of  the  hernia  will  prove  sufficient, 
having  the  horns  of  the  crescent  to  embrace  the  upper  and  lower 
extremities  of  the  gap  and  carried  as  a  wall  of  anesthesia  from  the 
skin  to  the  peritoneum.  (See  Figs.  81  and  92).  The  anesthetising 
of  the  tissues  is  done  in  the  same  manner  as  advised  for  umbilical 
hernia.  I  have  often  closed  large  postappendicular  herniae  in  this 
way,  and  have  found  it  very  satisfactory. 


CHAPTER  XIX 

GENITO-URINARY,  ANORECTAL,  AND  GYNECOLOGIC 
OPERATIONS 

GENITO-URINARY  ORGANS 

WHILE  the  pudic  nerve  is  the  principal  source  of  innervation  of 
the  deeper  parts  of  these  organs  (Fig.  93)  and  is  capable  of  a  fairly 
accurate  blocking  for  regional  anesthesia,  the  skin  of  these  parts  re- 
ceives its  nerve-supply  from  a  variety  of  sources  and  cannot  be  dealt 
with  collectively  except  by  such  more  or  less  central'  methods  as 
parasacral  or  epidural  injections,  thus  blocking  at  one  time  the  entire 
innervation  of  the  pelvis  and  a  large  part  of  the  lower  extremity. 

The  pudic  nerve  leaves  the  pelvis. through  the  great  sacrosciatic 
foramen,  crosses  the  spine  of  the  ischium  with  the  pudic  artery,  and 
re-enters  the  pelvis  through  the  lesser  sacrosciatic  foramen.  Accom- 
panying the  pudic  vessels,  it  runs  downward,  forward,  and  inward 
along  the  outer  wall  of  the  ischiorectal  fossa.  In  this  position  it  is 
about  i  inch  internal  to  the  tuberosity  of  the  ischium.  Here  it  gives 
off  its  perineal  and  inferior  hemorrhoidal  nerves,  then  continues  as  the 
dorsal  nerve  of  the  penis. 

The  inferior  hemorrhoidal  nerves,  several  in  number,  pass  down- 
ward, inward,  and  slightly  forward  from  the  above  position,  and  are 
distributed  to  the  sphincters  of  the  rectum  and  anal  canal. 

The  perineal  branches  pass  downward  and  forward  to  the 
perineum,  giving  off  branches  to  the  muscles  of  these  parts,  and 
are  distributed  to  the  skin  of  this  region,  branches  passing  for- 
ward to  the  scrotum  in  the  male  and  labia  majora  in  the  female. 
It  also  sends  a  branch  to  the  bulb  of  the  penis. 

The  dorsal  nerve  of  the  penis  pierces  the  posterior  layer  of  the 
deep  perineal  fascia,  and  runs  forward  along  the  inner  margin  of 
the  ramus  of  the  os  pubis  between  the  two  layers  of  deep  fascia. 
Further  forward  it  pierces  the  anterior  layer  of  the  fascia  and  passes 
through  the  suspensory  ligament  to  the  dorsum  of  the  penis.  In 
this  position  the  nerves  on  each  side  lie  to  the  outer  side  of  the 
artery  (Fig.  94) .  It  gives  off  a  large  branch  to  the  corpora  caverno- 
sum,  and  along  the  side  of  the  penis  branches  to  this  organ;  its 
terminal  filaments  are  distributed  to  the  glans  and  prepuce. 

379 


38o 


LOCAL   ANESTHESIA 


Levalor 


medial  infer,  cluneal 

inferior  haemorrhoidal 

artt 

int.  pudic 
vessels 
pudic 


Miiocoecygeal  nerves 

anococcygeal  lig. 

Glutaeus  maximus 

'uberous  lig. 
internal  pudic  art. 
uidic  nerve 

•ospinous  lig. 


BuWoau'trnosus 


\          dorsal  nerre  of  penis 
\  ^  arttiy  ojf,  urethra!  bulb 


art.  of  penis 


posfenor  scroial  arteries"'  • 

corpus  cavernosnm  of'urethra 


posterior  scrotal  nerves 


Fig.  93. — The  nerves  and  vessels  of  the  male  perineum  upon  the  left  side,  the 
superficial  perineal  musculature  has  been  exposed  and  the  ischiorectal  fat  removed; 
upon  the  right  the  transversus  perinei  superficialis  has  been  divided,  the  urogenital 
diaphragm  incised,  and  the  ischiocavernosus  drawn  slightly  to  one  side.  *  =  Bifurca- 
tion of  internal  pudic  artery  into  the  perineal  and  penile  arteries.  (Sobotta  and 
McMurrich.) 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    381 


Perineal  branches  of  the  small  sciatic  are  distributed  to  the  skin 
of  the  posterior  and  lateral  parts  of  this  region,  one  branch  larger  than 
the  others;  the  inferior  pudendal  curves  downward  and  inward 
around  the  tuberosity  of  the  ischium,  and  passes  forward  and  inward 


dorsal  artery  of  penis  fundiform  ligament 

dorsal  nerve  of  penis        ,  •      <tf  penis 

spermatic  ford        ^            \  \ 
\ 


dorsal  vein  of  penis 


external  spermatic 
vessels 


fascia  ofpei 


dorsal  ve, 
of  penis 


anterior 
scrotal  vessels 


subcutaneous 
vein  of  penis 


Fig.  94. — The  vessels  and  nerves  of  the  penis  spermatic  cord  and  scrotum  as  seen 
from  in  front.  The  skin  and  the  greater  portion  of  the  fascia  have  been  removed  from 
the  penis;  the  vessels  of  the  right  spermatic  cord  have  been  exposed  by  dividing  its 
coverings.  (Sobotta  and  McMurrich.) 

beneath  the  superficial  fascia  and  is  distributed  to  the  skin  of  the 
perineum — scrotum  in  the  male  and  the  labia  majorum  in  the  female. 
The  nerve  in  its  passage  around  the  tuberosity  lies  about  %  inch  to 
the  outside  of  the  bone,  between  it  and  the  great  sciatic  nerve. 

The  scrotum,  in  addition  to  its  branches  from  the  pudic  and  in- 
ferior pudendal,  receives  cutaneous  branches  from  other  sources, 


382  LOCAL   ANESTHESIA 

principally  the  ilio-inguinal,  and  probably,  on  its  anterior  part,  a  few 
branches  from  the  iliohypogastric.  Its  nerve-supply  is  such  that  all 
operations  done  upon  it  must  be  through  infiltration.  The  testicle, 
spermatic  cord,  and  cremaster  muscle  are  innervated  by  the  genital 
branch  of  the  genitocrural,  but  this  nerve  does  not  give  any  branches 
to  the  skin  overlying  these  parts. 

The  bladder  receives  two  nerves  on  each  side  from  the  third  and 
fourth  sacral,  which  enter  the  organ  near  its  base. 

Method  of  Blocking  Pudic  Nerve. — The  tuberosity  of  the  ischium 
is  located  as  a  landmark;  the  skin  over  a  point  about  i  inch  internal 
and  in  front  of  the  tuberosity  is  now  anesthetized;  a  large  syringe, 
containing  a  few  drams  of  0.50  per  cent,  novocain  solution,  with  2  or 
3  drops  of  adrenalin,  and  fitted  to  a  long  needle,  is  now  used.-  The 
needle  is  passed  downward  and  outward  toward  the  base  of  the  tuber- 
osity, varying  in  depth  according  to  the  stoutness  of  the  individual, 
but  usually  about  i^  to  2  inches;  at  a  point  about  %  inch  from  the 
base  of  the  tuberosity  2  or  3  drams  of  the  solution  are  injected.  The 
same  procedure  is  repeated  on  the  opposite  side;  or,  if  preferred,  the 
long  needle  may  be  entered  at  a  point  i^  or  2  inches  back  of  the 
anus  in  the  midline,  after  previously  anesthetizing  this  point  in  the 
skin,  and  directing  the  needle  obliquely  outward  and  upward  toward 
the  base  of  the  tuberosity  of  the  ischium,  guided  by  the  finger  within 
the  rectum,  when  2  or  3  drams  of  the  solution  are  injected  about  ^ 
inch  from  this  bone.  The  method  of  making  this  injection  is  shown 
in  Fig.  1 06.  The  needle  is  then  partially  withdrawn  and  turned  in 
the  opposite  direction,  where  the  injection  is  repeated.  These 
methods,  however,  are  not  often  used,  but  when  resorted  to  for 
operations  on  the  rectum  the  perianal  infiltration,  as  described  later, 
should  be  made  somewhat  more  liberal  posteriorly  between  the  anus 
and  the  coccyx  and  well  into  the  subcutaneous  tissue  to  reach  the 
nerves  that  come  into  the  field  from  this  direction.  The  uncertainty 
of  reaching  this  nerve  at  the  point  where  it  enters  the  pelvis  with  any 
degree  of  accuracy  for  a.paraneural  injection  has  led  to  efforts  to 
reach  it  from  without  by  an  injection  made  through  the  gluteal 
region.  This  procedure  has  been  recommended  by  Franke,  and  is 
done  as  follows:  The  skin  of  the  gluteal  region,  at  a  point  about  over 
the  spine  of  the  ischium,  is  located  by  a  finger  passed  within  the  rec- 
tum, and  the  long  needle  passed  down  from  without  through  the 
anesthetized  point  and  an  injection  made  in  contact  with  the  spine. 
Neither  of  these  methods  have  become  very  popular  with  others, 
and  are  rarely  if  ever  used  by  the  author.  The  methods  preferred 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   383 

are  those  described  in  dealing  with  the  different  regions,  as  de- 
scribed later. 

To  anesthetize  the  inferior  pudendal  nerve  an  injection  is  made  on 
the  outer  side  of  the  tuberosity  of  the  ischium,  where  this  nerve 
passes  close  to  the  base  of  the  process  and  between  it  and  the  great 
sciatic. 

The  needle  is  entered  in  the  perineum  to  the  inner  side  of  the 
tuberosity  and  directed  outward  and  upward,  injecting  as  the  needle 
is  advanced  to  a  point  over  the  base  of  the  bone;  the  injection  is 
made  after  the  needle  is  felt  to  pass  the  bone  about  %  inch,  usually 
using  about  2  drams  of  0.50  per  cent,  novocain  adrenalin  solution. 
This,  however,  like  the  injection  of  the  pudic,  is  uncertain. 

THE  PENIS 

To  anesthetize  the  entire  organ  a  circumferential  line  of  intra- 
dermal  anesthesia  is  carried  around  the  organ  at  its  root,  as  seen  in 


Fig.  95. — Method  of  procedure  for  anesthesia  of  entire  penis.     (From  Braun.) 

Fig.  95.  From  this  line  two  deep  injections  are  made  about  Y±  inch 
on  either  side  of  the  midline  and  carrTe4  down  to  the  corpora  caver- 
nosa  (Fig.  94),  showing  the  nerve-supply  and  (Fig.  96)  the  point  of 
injection,  using  here  about  i  dram  of  0.50  novocain  adrenalin  solution 
or  a  somewhat  more  liberal  injection  of  solution  No.  i. 

If  the  contemplated  procedure  involves  the  urethra,  a  smaller 
quantity  of  the  solution  should  be  injected  deep  on  either  side  of 


LOCAL   ANESTHESIA 

this  structure  in  the  sulcus,  between  it  and  the  corpora  cavernosa. 
Should  a  fine  needle  pierce  the  urethra  in  this  injection  no  damage  will 
result.  A  small  stationer's  elastic  band,  used  as  a  constrictor,  should 
now  be  placed  around  the  base  of  the  organ  proximal  to  the  injections, 
but  not  too  tightly,  for  fear  of  injury.  After  a  few  minutes'  delay 
anesthesia  is  produced.  Gentle  massage  helps  to  diffuse  the  solution, 
when  any  operation  involving  these  parts  may  be  undertaken,  from 
circumcision  to  amputation.  Urethrotomy,  internal  or  external,  as 
well  as  plastic  work,  involving  the  urethra  or  the  rest  of  the  organ, 


Fig.  96 — i,  Shows  line  of  anesthesia  for  suprapubic  cystotomy;  2,  points  on  each 
side  of  midline  for  paraneural  injection  of  dorsal  nerves  of  penis;  3,  area  of  anesthesia  for 
varicocele,  hydrocele,  or  orchidectomy. 

distal  to  the  point  of  injection,  can  now  be  painlessly  done.  The  above 
is  an  excellent  method  for  the  cauterization  of  extensive  or  phago- 
denic  chancroids  of  this  region  or  for  operations  for  paraphimosis. 

The  Oberst  Method. — This  is  really  a  form  of  arterial  anesthesia, 
and,  while  ingenious  and  effective,  may  at  times  be  followed  by  hema- 
toma,  and  for  that  reason  is  not  very  popular  with  the  writer. 

A  constrictor  is  placed  around  the  root  of  the  organ.  A  syringe 
and  fine  needle  filled  with  i  per  cent,  cocain  solution  (which  is  the  solu- 
tion recommended  by  Oberst,  though  novocain  could  also  be  used) 
is  now  injected  in  the  following  manner: 


GENITO-URINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    385 

The  needle  is  thrust  well  into  the  corpora  cavernosa,  and  from  5 
to  7  minims  of  the  solution  is  injected  (Fig.  97).  This  is  repeated 
on  the  opposite  side.  About  5  minims  of  the  solution  is  injected 
into  the  subcutaneous  tissues  on  each  side  of  the  organ,  and  about 
the  same  quantity  on  the  undersurface  around  the  urethra. 

Anesthesia  takes  place  in  about  fifteen  minutes,  and  is  usually 
very  satisfactory  and  sufficient  for  any  operation  upon  the  organ.  It 
has  been  especially  recommended  for  circumcision  as  a  substitute 
for  the  direct  method  of  infiltration,  on  the  ground  that  the  edematiza- 


Fig.  97. — The  Oberst  method  of  cocain  infiltration.  A  constrictor  is  first  placed 
around  the  root  of  the  organ  and  the  injection  made  with  a  very  fine  needle,  as  described 
below.  Oberst  recommends  a  i  per  cent,  solution  of  cocain,  but  the  same  strength  of 
novocain  could  also  be  used.  (Miller.) 

tion  of  the  tissues  resulting  from  infiltration  was  an  objection  in  this 
operation.  The  writer,  however,  has  not  found  this  to  be  the  case. 
Circumcision. — Solution  No.  i,  with  an  ordinary  hypodermic 
with  fine  needle,  is  sufficient.  The  skin  is  pulled  well  over  the  glans 
and  the  point  of  incision  determined.  The  injection  is  begun  just 
proximal  to  this  point  and  a  circumferential  injection  is  made  into 
the  subcutaneous  tissues  around  the  organ.  If  the  prepuce  is  well 
relaxed  and  can  be  freely  retracted,  a  finger  is  passed  up  on  its  inner 
surface  between  it  and  the  glans.  The  needle  is  now  directed  down 
through  the  already  anesthetized  parts  on  the  surface  toward 
25 


386 


LOCAL   ANESTHESIA 


this  point,  injecting  as  it  is  advanced,  until  it  reaches  a  point  on  the 
inner  surface  of  the  prepuce  just  back  of  the  cervix  (neck  of  the  glans). 
A  station  is  produced  here,  the  prepuce  now  retracted,  and,  begin- 
ning at  this  anesthetized  point,  a  collar  of  anesthesia  is  created  around 
the  glans,  carrying  it  well  into  the  frenum;  or,  instead  of  the  above, 
the  prepuce  can  be  reflected  and  the  anesthesia  started  from  an 
injection  made  from  the  inner  surface.  Anesthesia  will  now  be  com- 
plete and  the  operation  can  be  performed.  A  small  stationer's  elastic 
should  first  be  applied  as  a  constrictor  around  the  organ  near  its 
base.  In  the  event  that  the  prepuce  is  very  tight  and  cannot  be  re- 
tracted, it  may  be  filled  with  a  i  per  cent,  solution  and  held  for  a  few 
minutes,  or  the  injection  can  be  carried  forward  toward  the  con- 


Fig.  98. — Anesthetizing  dorsal  surface  of  foreskin  from  periphery  toward  base.     (From 

Braun.) 

stricttd  opening  and  this  anesthetized  and  divided  sufficiently  to 
permit  retraction,  when  its  inner  surface  can  be  anesthetized;  or  the 
procedure  as  illustrated  in  Fig.  98  may  be  carried  out. 

The  Urethra.— Two  or  3  drams  of  i  or  2  per  cent,  novocain  solu- 
tion and  i  or  2  drops  of  adrenalin  held  in  the  urethra  for  five  or  ten 
minutes  will  anesthetize  the  mucosa  sufficiently  to  permit  a  painless 
internal  urethrotomy  or  the  gradual  dilatation  of  a  stricture,  but 
will  not  permit  divulsion  (which,  however,  is  now  rarely  practised), 
as  it  does  not  anesthetize  the  submucous  and  periurethral  tissues. 
Stronger  solutions  than  i  or  2  per  cent,  are  never  necessary  here. 
The  same  effects  can  be  obtained  with  the  weaker  solutions  if  re- 
tained slightly  longer.  The  urethra  absorbs  very  actively,  and 
many  cases  of  poisoning,  at  times  fatal,  have  been  reported  from  the 


GENITO-URINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   387 

injudicious  use  of  strong  solutions;  consequently,  one  should  never 
be  tempted  by  haste  to  exceed  the  safe  limits. 

In  irrigating  a  sensitive  urethra  by  the  Valentine  method,  or  one 
in  which  the  cut-off  muscle  will  not  readily  relax,  this  muscular 
contraction  can  be  easily  overcome  by  first  filling  the  urethra  with  a 
weak  anesthetic  solution  for  a  few  minutes  as  above  suggested. 

The  use  of  adrenalin  solution  when  retained  a  few  minutes  in  the 
urethra  is  often  of  great  advantage,  particularly  in  inflamed  or  con- 
gested conditions;  the  relaxation  following  the  congestion  will  often 
permit  the  easy  passage  of  an  instrument  which  would  seem  impos- 
sible or  very  difficult  without  its  use.  Strictures  which  have  been 
congested  following  alcoholic  indulgence,  causing  acute  retention  of 
urine,  can  often  be  sufficiently  relieved  in  this  way  to  permit  the 
passage  of  a  small  catheter  when  an  external  urethrotomy  would 
otherwise  have  seemed  indicated. 

Where  the  stricture  or  field  of  operation  is  in  the  penile  portion  of 
the  urethra  a  very  satisfactory  and  exact  method  of  anesthesia  is  to 
inject  the  tissues  circumferentially  around  the  urethra  by  passing  a 
fine  needle  down  to  this  structure  from  the  under  surface  of  the 
penis.  This  is  done  just  proximal  to  the  field  and  after  a  few 
minutes  delay  will  anesthetize  the  uretha  for  a  considerable  distance 
in  front  of  the  injections.  If  the  entire  penile  urethra  is  to  be 
anesthetized,  two  points  may  have  to  be  injected.  This  method 
anesthetizes  the  entire  urethra  and  is  devoid  of  any  danger  which 
may  at  times  occur  from  absorption  when  strong  solutions  are  injected 
within  the  urethra  and  which  at  most  anesthetize  only  the  mucous 
membrane. 

The  Meatus. — To  anesthetize  the  meatus  a  very  satisfactory 
method  is  to  dip  the  end  of  a  moistened  sterile  probe  into  a  bottle 
of  cocain  or  novocain  crystals,  when  a  few  of  the  crystals  will  adhere 
to  the  end  and  can  be  conveniently  deposited  in  the  meatus.  In  a 
few  minutes  this  will  have  produced  sufficient  anesthesia  to  permit 
fairly  considerable  dilatation  for  the  passage  of  a  sound  through  a 
tight  meatus,  and  will  also  permit  a  limited  meatotomy.  But  it  is 
better  for  the  latter  to  infiltrate  the  meatus  in  the  line  of  the  pro- 
posed incision  with  a  few  drops  of  solution  No.  i. 

The  female  urethra  is  easily  anesthetized  by  a  few  drops  of  5  or 
10  per  cent,  novocain  on  a  film  of  cotton  wrapped  around  an  appli- 
cator, and  passed  into  the  urethra  for  a  few  minutes. 

External  urethrotomy  in  the  ordinary  case  is  quite  easily  per- 
formed under  local  anesthesia.  In  the  presence  of  extensive  urinary 


388 


LOCAL   ANESTHESIA 


infiltration  it  may  prove  difficult  and  test  the  ability  of  any  but  an 
experienced  operator  .under  local  measures,  as  the  fibrous  tissue  en- 
countered under  these  conditions  is  difficult  of  thorough  infiltration. 

If  the  strictured  point  is  deeply  situated  the  pudic  and  pudendal 
nerves  had  best  be  blocked,  though  it  is  possible  to  proceed  entirely 
with  infiltration,  which  is  the  method  preferred. 

The  urethra  is  first  anesthetized,  a  sound  passed,  and  the  stric- 
tured point  located  or  a  guide  or  filiform  passed  through  it.  Infil- 
tration is  commenced  in  the  middle  line  (Fig.  99),  just  proximal  to 
the  stricture,  and  carried  well  down  into  the  subcutaneous  tissues. 


Fig.  99. — Line  of  infiltration  for  external  urethrotomy. 

These  are  now  divided,  infiltrating  further  as  we  advance,  until  the 
urethra  is  reached,  when  a  little  solution  injected  periurethrally 
around  the  strictured  point  will  permit  its  painless  division  or  resec- 
tion, if  not  too  extensive,  with  subsequent  approximation  and  suture 
of  the  divided  ends  of  the  urethra. 

In  cases  in  which  the  stricture  is  long  and  tortuous  or  in  which 
there  are  several,  the  urethra  is  incised  at  the  distal  end  of  the  stric- 
ture and  its  lumen  opened  by  retraction,  exposing  the  strictured 
orifice,  when  under  direct  guidance  of  the  eye  a  much  larger  instru- 
ment can  be  passed  backward  toward  the  bladder,  and  the  exact  course 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   389 

of  the  urethra  recognized  through  the  tissues,  when  a  long  needle  can 
be  passed  down  in  close  contact  with  it  and  the  tissues  injected. 
This  is  best  done  on  both  sides  and  will  permit  the  free  incision 
of  these  parts  or  their  dilatation  as  preferred.  In  cases  in  which 
the  stricture  is  very  dense  and  its  lumen  hard  to  follow  with  any 
instrument,  the  urethra  can  be  opened  at  the  distal  end  of  the  stric- 
ture after  freely  infiltrating  the  perineum,  the  strictured  urethra  is 
then  progressively  followed  backward  infiltrating  as  you  advance 
until  a  patulous  portion  of  the  urethra  is  encountered. 

The  following  history  of  a  patient  operated  on  by  the  author 
illustrates  a  procedure  which  may  sometimes  prove  useful: 

Mr.  A.,  aged  forty-three,  alcoholic,  with  chronic  endocarditis  and  history  of  renal 
disease,  presented  himself,  with  a  large  infiltrated  scrotum  with  urinary  fistulae  on  inner 
side  through  which  urine  and  pus  dribbled,  only  a  few  drops  appearing  at  the  meatus 
during  efforts  at  urination.  It  was  found  impossible  to  pass  a  sound  or  filiform  through 
the  tortuous  fibrous  urethra.  Through  infiltration  of  the  tissues  at  the  base  of  the  scro- 
tum an  incision  was  made  down  to  about  the  position  of  the  urethra,  but  it  was  found  im- 
possible to  readily  identify  this  structure.  The  wound  was  packed  and  suprapubic  cys- 
totomy  done,  liberating  a  large  amount  of  foul  urine.  In  the  Trendelenburg  position 
(to  dilate  the  bladder  with  air)  the  internal  urethral  orifice  was  readily  seen,  and  a  small 
Poges  silk-woven  catheter  passed  forward  along  the  urethra.  This  caused  no  discom- 
fort. At  a  distance  of  about  3  inches  the  point  of  the  catheter  was  arrested.  While  it 
was  held  in  this  position  by  an  assistant  we  returned  to  the  perineal  wound.  Some 
additional  infiltration  was  found  necessary  here,  as  the  parts  had  become  sensitive. 
The  urethra  was  now  readily  recognized  in  a  mass  of  fibrous  tissue  by  manipulation  of 
the  catheter  and  opened.  The  anterior  portion  of  the  urethra  was  easily  followed  and 
several  strictures  divided  under  infiltration. 

The  case  made  an  uneventful  recovery.  The  urinary  fistulae  on 
the  side  of  the  scrotum  closed  without  any  special  treatment.  Sub- 
sequent examination  of  the  urine  showed  albumin  and  granular  casts. 

This  case  would  certainly  have  been  a  dangerous  risk  with  general 
anesthesia.  Spinal  analgesia  could,  however,  have  been  employed, 
but  we  resort  to  the  latter  only  when  local  and  regional  methods  are 
impracticable.  These  cases  with  extensive  infiltration  and  multiple 
fistulae  are  particularly  well  suited  to  epidural  injections,  which  see. 

Epispadias  and  hypospadias,  or  other  plastic  operations,  are  usu- 
ally quite  easily  performed  under  local  anesthesia,  but  should  not  be 
done  under  infiltration.  Instead,  the  regional  method  of  blocking  the 
nerves  of  the  root  of  the  organ  as  already  mentioned  should  be  em- 
ployed; when  extensive,  always  combining  the  operation  with  an  ex- 
ternal urethrotomy. 

SCROTUM 

All  operations  upon  the  scrotum  can  be  performed  under  infiltra- 
tion. Where  resections  are  to  be  done,  as  in  the  case  of  superficial 


390 


LOCAL   ANESTHESIA 


Fig.  100. — Method  of  surrounding  penis  and  scrotum  with  zone  of  anesthesia  for  opera- 
tions upon  scrotum.     (From  Braun.) 


Fig.  101. — Method  of  injecting  posterior  surface  of  scrotum.     (From  Braun.) 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    391 

growths  or  for  elephantiasis,  a  zone  of  anesthesia  should  be  created 
around  the  part  to  be  excised.  If  it  involves  the  entire  organ,  infil- 
tration should  be  done  around  the  base  (Figs.  100  and  101).  If  the 
operation  involves  the  contents  of  the  scrotum,  the  cord  should  be 
exposed  just  below  the  spine  of  the  pubis  on  one  or  both  sides,  as  the 
case  may  require,  and  blocked  there.  The  genitocrural  nerve  lies  at 
the  back  of  the  cord,  near  the  vas  (Figs.  94  and  102).  By  infiltrating 
the  cord  freely  in  this  position  the  nerve  is  reached ;  it  is  not  necessary 
to  directly  expose  it.  In  making  an  injection  here  care  should  be 
taken  not  to  enter  any  of  the  large  veins  which  may  be  found  in  this 
region.  Make  the  injection  only  when  advancing  or  withdrawing 
the  needle,  not  when  the  needle  is  stationary,  unless  the  parts  are 
plainly  in  view. 

The  following  case,  operated  on  by  Prof.  Matas,  illustrates  the 
possibilities  here: 

"An  adult  negro  laborer  was  admitted  in  my  service  in  the  Charity  Hospital  two 
years  ago  for  the  removal  of  an  immense  scrotal  tumor,  which  extended  from  the  pubes 
to  the  knee.  After  making  a  linear  infiltration,  13  inches  in  length,  in  the  vertical  axis 
of  the  tumor,  we  reached  a  hernial  sac  which  contained  the  cecum  and  a  long  appendix 
vermiformis.  The  hernial  region  was  anesthetized.  The  appendix  was  removed,  the 
sac  excised,  and  the  hernial  canal  closed  by  a  Bassini  operation.  The  dissection  was 
then  continued,  and  two  enormous  polycystic  masses  (originally  hydroceles  of  the  cord 
and  tunica  vaginalis),  containing  over  3  pints  of  fluid,  were  tapped  and  excised  with  the 
testis,  which  was  incorporated  in  their  walls.  The  patient  never  complained  during  this 
long  and  tedious  procedure,  and  enjoyed  a  hearty  meal  shortly  after  returning  to  the 
ward.  He  made  a  perfectly  uneventful  recovery." 

Operations  Upon  the  Scrotal  Contents.- — Varicocele,  hydrocele, 
castration,  etc.,  can  all  be  done  following  a  uniform  method  of  anes- 
thesia. For  typical  operations  this  is  as  follows:  The  skin  on  the 
anterior  surface  is  infiltrated  longitudinally  for  about  3  or  4  inches 
(Fig.  96).  If  the  operation  is  for  varicocele  or  for  an  orchidectomy, 
the  upper  end  of  this  line  should  begin  at  the  spine  of  the  pubis;  if 
for  hydrocele,  it  may  be  lower,  and  the  lower  end  reach  well  over  the 
surface  of  the  tumor,  but  the  upper  end  must  reach  sufficiently  high 
to  permit  ready  access  to  the  cord  above.  The  cord  is  now  picked  up 
through  the  scrotal  wall  with  the  finger,  and  the  small  needle  passed 
through  the  anesthetized  area  at  its  upper  end  and  an  injection  made 
on  each  side  of  the  cord  (Fig.  102)  in  close  contact  with  it;  some  opera- 
tors inject  within  the  cord  in  this  way,  but  I  find  it  better  not  to  do  so, 
as  a  vein  might  be  injured,  and,  while  of  no  consequence,  it  might 
produce  a  hematoma  or  discolor  the  field  with  blood,  and  as  the 
cord  is  to  be  later  exposed  nothing  is  gained.  The  incision  is  then 


392  LOCAL   ANESTHESIA 

made  through  the  anesthetized  skin  and  fascia  down  to  the  cremas- 
teric  fascia  >  this  is  divided  and  the  cord  freely  exposed  and  drawn  out 
of  the  wound;  the  deep  injections  previously  made  around  the  cord 
permit  this  manipulation  without  discomfort.  With  the  cord  now 
freely  exposed  out  of  the  wound  it  can  be  thoroughly  injected  with 
the  small  syringe;  the  genitocrural  nerve  lies  at  the  back  of  the  cord 
near  the  vas,  but  all  veins  should  also  have  a  wall  of  anesthesia  around 
them,  as  they  are  sensitive.  These  injections  are  all  made  high  up 
at  the  proximal  end  of  the  field.  Having  completed  this  procedure, 
the  entire  scrotal  contents  are  anesthetic,  and  any  contemplated 


Fig.  102. — Method  of  infiltrating  around  spermatic  cord. 

operation  can  be  performed.  The  testicle  can  be  drawn  out  of  the 
scrotum  and  freely  exposed  to  view,  but  traction  should  not  be  made 
upon  the  upper  end  of  the  cord,  as  this  pulls  upon  the  unanesthetized 
parts  above  and  will  produce  pain. 

If  the  condition  is  one  of  varicocele,  the  veins  of  the  entire  cord 
and  about  the  epididymis  can  be  resected. 

If  for  hydrocele,  the  inversion  operation  or  the  removal  of  the 
parietal  portion  of  the  tunic,  as  in  the  Volkmann  operation,  can  be 
performed  with  equal  satisfaction. 

In  the  event  of  inflammation  creating  adhesions  within  the  scro- 


GENITOURINARY,  ANORECTAL,  AND   GYNECOLOGIC  OPERATIONS    393 

turn,  these  may  have  to  be  infiltrated  before  the  sac  can  be  dissected 
away  freely,  particularly  about  the  septum,  for  here  nerve-filaments 
cross  over  from  the  other  side. 

In  operations  for  hydrocele  it  has  been  suggested  that  the  tunica 
vaginalis  be  filled  for  a  few  minutes  with  a  i  per  cent,  solution  of  novo- 
cain,  after  first  drawing  off  its  contents.  This,  however,  is  not  neces- 
sary if  the  cord  has  been  properly  blocked,  as  the  entire  parts  are 
anesthetized.  This  procedure  may,  however,  be  done  through  a 
cannula  for  the  injection  of  irritating  substances  like  iodin,  but  is 
hardly  necessary  for  carbolic  acid  if  the  sac  is  first  thoroughly 
emptied. 

CHANCROIDS 

The  topical  application  of  cocain  or  other  agents  except  carbolic 
acid,  even  in  very  strong  solutions,  for  the  purpose  of  producing  anes- 
thesia to  permit  the  painless  cauterization  of  these  lesions,  is  quite 
unsatisfactory,  even  for  the  use  of  nitric  acid,  the  anesthetic  effect 
of  the  agent  not  penetrating  deep  enough.  A  satisfactory  method  of 
treating  these  lesions  is  to  first  dry  them  thoroughly  and  then  to 
apply  pure  carbolic  acid.  This  rarely  causes  any  complaint  or,  if  so, 
too  trifling  to  be  of  consequence.  If  a  more  thorough  cauterization 
than  that  produced  by  carbolic  acid  is  desired,  nitric  acid  can  now  be 
added,  and  if  not  too  liberally  done,  its  action  will  be  found  painless. 
In  using  either  of  these  agents  this  way  care  should  be  taken  not  to 
permit  them  to  run  over  the  skin  of  the  surrounding  parts.  If  the 
lesion  is  very  superficial,  this  can  be  prevented  by  surrounding  it 
with  a  smear  of  vaselin. 

Cataphoresis  can  be  made  use  of  for  carrying  anesthetic  drugs 
into  the  tissues  in  such  lesions  as  chancroids.  The  objection  to  the 
method  is  the  time  necessary  for  the  agent  to  penetrate  to  suffi- 
cient depth  to  produce  satisfactory  operative  anesthesia.  It  is, 
nevertheless,  possible. 

A  pledget  of  cotton  saturated  with  a  10  per  cent,  solution  of  the 
agent  to  be  employed  is  placed  over  the  lesion.  The  positive  elec- 
trode is  placed  over  this  and  the  negative  at  some  nearby  part  of  the 
body.  A  mild  galvanic  current  is  used,  when  after  about  fifteen  to 
twenty  minutes,  sometimes  longer,  it  will  be  found  that  the  anesthetic 
has  penetrated  to  a  sufficient  depth  to  permit  the  painless  use  of  the 
galvano-  or  thermocautery.  The  time  consumed  in  this  process 
renders  it  impracticable  for  the  busy  practitioner.  A  more  satisfac- 
tory method  is  the  following:  When  the  lesion  is  situated  upon  any 


394  LOCAL   ANESTHESIA 

part  of  the  foreskin  the  surrounding  parts  are  well  cleansed;  a  fine 
needle  fitted  to  a  syringeful  of  solution  No.  i  is  entered  some  little 
distance  from  the  lesion,  after  first  touching  the  skin  at  this  point 
with  tincture  of  iodin.  As  the  needle  is  advanced  the  solution  is  in- 
jected until  the  surface  beneath  the  lesion  is  reached,  when  the 
entire  underlying  subcutaneous  tissue  is  infiltrated.  This  can  be 
facilitated  by  sliding  the  skin  toward  the  needle,  rather  than  make 
several  punctures  with  the  needle,  which  may  carry  infection  down 
with  it.  To  replenish  the  syringe  the  needle  is  left  in  the  tissues 
and  the  syringe  unscrewed,  refilled,  and  fitted  on  again.  After 
thorough  infiltration  the  actual  cautery  can  be  used.  Where  the 
lesion  is  too  large,  where  there  are  several  in  different  parts,  or  where 
they  are  situated  upon  the  glans,  the  method  of  nerve-blocking,  as 
previously  described,  had  better  be  employed. 

THE  BLADDER 

The  fundus  of  the  normal  bladder  is  almost  insensitive  to  pain. 
The  base  and  neck  are  quite  sensitive,  but  when  inflamed  even  the 
fundus  may  become  sensitive.  According  to  Lennander,  the  pain 
caused  by  the  overdistention  of  the  normal  bladder  is  due  to  the 
stretching  of  its  peritoneal  covering.  Traction  upon  the  bladder  wall 
will  cause  pain.  Any  pain  induced  when  operating  upon  the  blad- 
der, even  at  the  fundus,  is  always  referred  to  its  neck,  the  urethra, 
and  head  of  the  penis.  Certain  manipulations  may  sometimes 
produce  an  urgent  desire  to  urinate,  although  the  bladder  may  be 
open  and  empty.  In  the  uninflamed  bladder  such  operations  as 
lithotrity  or  suprapubic  cystotomy  for  the  removal  of  stones  or 
pedunculated  growths  is  quite  easily  carried  out  under  local  anesthe- 
sia. But  in  the  acutely  inflamed  or  old  chronically  inflamed  and 
contracted  bladder  such  operations  may  give  some  difficulty  and 
will  have  to  be  handled  gently  under  such  methods  as  infiltration 
and  topical  applications,  and  had  best  be  operated  by  regional 
methods.  (See  Parasacral,  Epidural,  and  Spinal  Anesthesia.) 

Antipyrin  was  formerly  much  used  as  a  vesical  anesthetic,  due  to 
its  possessing  styptic  and  mild  antiseptic  properties,  but  since  the 
advent  of  adrenalin  it  is  now  rarely  used. 

In  the  normal  bladder  the  power  of  absorption  is  very  limited,  but 
much  more  active  in  the  urethra.  In  the  acutely  inflamed  bladder 
the  power  is  much  increased,  and  is  always  more  active  at  the  base. 

To  anesthetize  the  neck  of  the  bladder  or  posterior  urethra,  for 


GENITO-URINARY,   ANORECTAL,  AND   GYNECOLOGIC  OPERATIONS    395 

the  practice  of  cystoscopy,  etc.,  it  is  more  convenient  to  use  small 
tablets  of  alypin  or  novocain  containing  from  ^  to  i  gr.,  which  are 
deposited  at  the  desired  point  by  specially  constructed  depositors 
made  for  this  purpose  (Fig.  103).  After  using  any  anesthetic,  either 
solution  or  tablet,  it  is  necessary  to  wait  from  ten  to  fifteen  minutes 
for  the  full  effect  to  be  felt.  Alypin  has  become  quite  a  favorite 
with  urologists  where  it  is  desirable  that  the  anesthetic  used  should 
not  produce  any  changes  in  the  appearance  of  the  tissues  by  vascular 
constriction.  This  power  alypin  possesses  probably  better  than  any 
other  commonly  used  anesthetic,  besides  being  decidedly  active  as 


Fig.  103. — Bransford  Lewis  depositor  (lightly  reduced  in  size)  for  depositing  anes- 
thetic tablets  at  neck  of  bladder  and  in  posterior  urethra.  The  curved  figure  with  the 
round  end  is  the  obturator;  the  other  has  a  flat  end  and  is  intended  to  push  the  tablet 
home  after  obturator  has  been  withdrawn  and  tablet  dropped  into  lumen  of  cannula. 

an  anesthetic,  penetrating  the  tissues  readily,  and  much   less  toxic 
than  cocain. 

PROSTATECTOMY 

In  presenting  a  subject  as  important  as  prostatectomy,  there 
are  many  facts  which  at  times  may  be  of  vital  importance  which  do 
not  deal  with  the  technical  performance  of  the  operation,  or  with  the 
details  of  anesthesia,  and  yet  which  are  little  understood  and  often 
omitted  in  the  practice  of  many  fairly  competent  men.  A  thorough 
knowledge  of  these  essentials  with  the  judgment  necessary  for  their 
application  often  distinguishes  the  surgeon  from  the  operator. 


396  LOCAL   ANESTHESIA 

General  Considerations. — My  discussion  of  these  details  is  due 
to  the  appreciation  of  their  importance,  as  their  omission  may  lead 
to  error  and  bring  to  discredit  a  method  which  I  am  convinced  has 
much  to  commend  it. 

One  factor  of  great  importance  is  the  age  of  these  patients,  as 
most  of  the  cases  requiring  surgical  relief  for  this  condition  have 
reached  or  passed  middle  age,  and  many  of  them  are  infirm  or  weak- 
ened by  suffering  and  infection.  In  the  old  and  feeble,  prostatectomy 
is  a  formidable  operation,  though  not  attended  by  a  greater  mortality 
than  that  following  any  other  major  operation  in  the  same  class  of 
patients.  However,  it  may  even  show  a  more  favorable  comparison 
by  observing  certain  methods  in  the  handling  of  these  cases. 

The  method  which  I  wish  to  present  is  the  result  of  a  process  of 
gradual  evolution  and  improvement  in  handling  these  patients. 
Beginning  with  the  two-stage  operation  and  the  adoption  of  the 
anoci-association  principles  to  control  shock,  and  the  logical  addition 
of  adrenalin  for  the  control  of  hemorrhage,  it  has  gradually  progressed 
to  the  point  of  complete  elimination  of  all  general  anesthetics, 
which  are  now  never  necessary,  but  which,  however,  should  be 
preferred  in  undoubted  malignancy  of  the  prostate  in  which  methods 
of  infiltration  should  be  avoided. 

The  Control  of  Shock. — The  particular  advantage  claimed  for 
local  anesthesia  in  this  field  is  the  avoidance  of  all  shock.  The  two 
great  factors  in  the  production  of  shock  are  trauma  and  hemorrhage, 
and  to  these,  in  the  great  majority  of  surgical  procedures,  is  added  the 
toxemia  of  the  general  anesthetic.  In  the  recent  and  more  improved 
methods  of  general  anesthesia  toxemia  may  be  practically  eliminated 
as  a  shock-producing  factor,  yet  general  anesthesia,  nevertheless,  has 
its  dangers  in  the  deranged  stomach,  possible  pulmonary,  and  par- 
ticularly in  prostatectomy,  renal,  complications. 

Dangers  Peculiar  to  Prostatics  and  Prostatectomy.- — These  cases 
present  another  danger  fully  as  great  as  any  of  the  above,  which  I 
believe  is  responsible  for  a  large  proportion  of  the  mortality  in  these 
patients,  a  danger  peculiar  to  these  cases. 

Few  persons  requiring  prostatectomy  present  themselves  for 
operation  before  they  have  seriously  felt  the  inconvenience  of  this 
condition;  many  have  probably  already  been  initiated  into  catheter 
life;  some  have  had  one  or  more  attacks  of  acute  retention  of  urine 
from  prostatic  congestion,  and  practically  all  will  show  considerable 
residual  urine  and  possibly  some  renal  complications;  nearly  all  are 
disturbed  frequently  at  night  by  having  to  arise  to  urinate.  The 


GENITOURINARY,  ANORECTAL,  AND   GYNECOLOGIC  OPERATIONS    397 

kidneys  have  gradually  accustomed  themselves  to.  this  condition 
and  are  working  against  considerable  back  pressure,  and  the  sudden 
relief  of  this  pressure  at  operation  completely  upsets  the  renal  equilib- 
rium leading  to  congestion  with  diminished  excretion  or  probably 
anuria.  Here  lies  the  particular  danger  in  these  cases,  and  to  avoid  it 
we  must  first  relieve  the  bladder  and  permit  the  kidneys  to  recover  by 
performing  these  operations  in  at  least  two  stages  in  all  cases  that  show 
much  residual  urine  or  are  siiffering  from  retention  at  the  time  of 
operation.  The  danger,  too,  of  suddenly  relieving  a  distended  bladder 
in  these  cases  cannot  be  overestimated;  vesical  hemorrhage  may  occur, 
associated  with  renal  suppression.  In  my  observation,  this  procedure 
alone  has  caused  as  great  a  mortality  as  prostatectomy. 

In  extreme  cases  such  bladders  should  never  be  opened  at  once, 
unless  badly -infected  and  the  danger  of  general  infection  too  great 
for  delay.  They  should  be  gradually  evacuated  by  catheter,  remov- 
ing but  a  portion  of  the  urine  at  a  time,  at  two  or  three-hour  intervals, 
or  if  almost  completely  emptied  one-fourth  to  one-third  as  much 
boric  acid  solution  reinjected  as  there  was  urine  removed.  This 
gradual  emptying  process  should  consume  from  twenty-four  to 
forty-eight  hours  before  the  bladder  is  opened. 

Preliminary  Cystotomy.' — Rarely  a  case  is  met  with  in  which  there 
is  considerable  distention  and  the  passage  of  a  catheter  too  painful, 
difficult,  or  even  impossible  of  accomplishment.  In  such  cases,  if 
the  suprapubic  incision  is  carried  down  to  the  bladder,  the  bladder 
can  then  be  emptied  by  a  gradual  process  of  aspiration  at  intervals 
of  several  hours,  gradually  withdrawing  more  and  more  at  each 
successive  aspiration,  thus  overcoming  the  difficulty.  During  these 
intervals  the  suprapubic  wound  is  kept  packed.  After  twenty-four 
or  forty-eight  hours  the  bladder,  which  is  now  fairly  collapsed,  may  be 
opened  with  safety. 

The  method  of  performing  the  cystotomy  and  of  dealing  with  the 
bladder  afterward  is  of  some  consequence.  It  may  be  opened  with 
a  free  incision  with  the  introduction  of  a  tube  or  catheter  to  its  base 
and  the  attachment  of  some  syphoning  apparatus,  or  the  escape  of 
urine  may  be  effectively  controlled  by  making  a  small  buttonhole 
opening  into  which  is  passed  a  Pesser  catheter.  The  incision  is 
then  infolded  and  held  by  two  stitches,  one  placed  on  either  side  of 
the  catheter.  Such  a  valve-like  closure  will  leak  very  little,  if  at 
all. 

The  advantage  of  this  last  method  is  quite  apparent,  as  it  permits 
the  collection  of  all  urine  and  in  this  way  the  functional  activity  of 


398  LOCAL   ANESTHESIA 

the  kidneys  can  be  accurately  gauged.  It  will  usually  be  found  that 
the  urinary  excretion  for  the  first  two  days  diminishes  considerably 
following  the  cystotomy,  gradually  increasing  from  the  third  to  the 
fifth  day,  and  is  about  normal  by  the  end  of  the  first  week.  By  this 
time,  if  the  patient's  general  condition  is  good  as  shown  by  normal 
appetite  with  good  digestion,  free  bowel  movements  and  after  a  few 
nights'  normal  restful  sleep,  free  from  the  annoyance  of  frequent 
urinations,  the  removal  of  the  prostate  can  be  undertaken.  It  is 
usually  noticed  that  the  prostate  diminishes  decidedly  in  size  follow- 
ing the  cystotomy  due  to  the  relief  of  the  congestion  and  this  diminu- 
tion in  size  facilitates  its  later  removal. 

Functional  Kidney  Tests. — If  any  question  exists  regarding  the 
condition  of  the  kidneys  a  further  delay  is  necessary  or  their  capacity 
may  be  tested  by  phenolsulphonephthalein,  and  under  no  conditions 
should  the  prostatectomy  be  attempted  until  they  have  reached  a 
fairly  normal  condition  of  elimination.  By  handling  patients  in 
this  way  many  bad  risks  and  feeble  individuals  may  be  safely  carried 
through  the  surgical  ordeal. 

During  the  interval  between  the  suprapubic  cystotomy  and  the 
prostatectomy  the  bladder  should  be  washed  once  or  more  daily 
with  warm  boracic  solution  and  the  suprapubic  wound  kept  lightly 
packed,  and  any  infection  in  the  cellular  planes  which  may  have 
occurred,  which,  however,  is  rare,  should  be  well  under  control 
before  the  final  operation  is  attempted. 

Improving  Poor  Surgical  Risks. — Occasionally  a  case  is  met 
with  in  which  the  kidneys  seem  to  have  recovered  their  normal 
equilibrium  as  shown  by  the  output  of  urine,  and  the  patient  relieved 
of  all  vesical  symptoms  yet  seems  much  depressed  with  loss  of 
weight  and  poor  appetite.  Such  cases  should  not  have  the  final 
stage  of  the  operation  completed  until  they  have  fully  regained 
their  normal  and  show  improvement  in  weight  and  appetite. 

Nothing  improves  these  cases  more  than  frequent  tub  baths. 
There  is  no  danger  of  harming  the  bladder  or  infecting  it  by  complete 
immersion,  but  it  is  usually  best  to  give  the  bladder  irrigation  follow- 
ing the  bath.  If  the  patient  is  too  feeble  to  walk,  he  is  gotten  out  in 
a  rolling  chair  and  kept  in  the  fresh  air  and  sunshine  as  much  as  pos- 
sible; when  he  is  able  to  be  on  his  feet  some  form  of  urinal  is  used  to 
keep  him  dry  and  he  is  encouraged  to  get  about  as  much  as  possible. 
Unless  the  kidneys  have  been  badly  damaged  by  ascending  infection 
or  other  complications  exist,  such  cases  will  soon  show  sufficient 
improvement  to  safely  permit  the  final  step  in  the  operation. 


GENITOURINARY,  ANORECTAL,   AND  GYNECOLOGIC  OPERATIONS  3QQ 

Technic  for  Suprapubic  Cystotomy. — For  the  suprapubic  cys- 
totomy  the  bladder  is  first  irrigated  freely  through  a  catheter  with 
boracic  acid  solution  and  left  moderately  distended. 

It  is  better  to  complete  the  infiltration  of  the  entire  field  of 
operation  before  making  the  incision;  it  is  quicker,  takes  less  solu- 
tion and  produces  a  more  profound  anesthesia.  To  do  this  quickly 
and  accurately  requires  some  little  skill  and  delicacy  of  technic, 
which,  however,  can  be  readily  acquired  with  a  little  practice  and 
careful  attention  to  detail. 

Infiltration. — This  is  done  in  the  following  manner:  An  intrader- 
mal  wheal  is  produced  in  the  skin  about  the  middle  of  the  proposed 


Fig.  104. — A,  Introdermal  wheal  through  which  all  injections  are  made;  B,  in- 
jecting rectal  sheath;  C-D,  dilatation  of  bladder;  E,  reflection  of  peritoneum  during 
dilatation;  F,  prostate  and  sheath;  G,  suppository  of  anesthesin. 


incision,  this  is  used  as  a  station,  a  long  fine  needle  is  entered  at  this 
point  and  directed  upward  under  the  skin  in  the  subcutaneous  tissues 
injecting  as  the  needle  is  advanced  the  full  length  of  the  proposed 
incision,  the  needle  is  partly  withdrawn  and  directed  downward  in 
the  opposite  direction  toward  the  pubes  and  the  tissues  here  simi- 
larly infiltrated.  The  needle  having  once  entered  the  skin  is  not 
withdrawn  completely  until  the  entire  field  is  injected,  by  partly 
withdrawing  it  its  point  can  be  directed  in  different  directions,  as 
all  parts  of  the  field  can  be  easily  reached  from  a  common  point  of 
injection;  in  this  way  the  unnecessary  trauma  from  repeated  punc- 


4OO  LOCAL   ANESTHESIA 

tures  of  the  skin  is  avoided.     During  the  passage  of  the  needle 
through   the    tissues   the   precaution   is   observed   of   continuously 
injecting  the  solution  when  the  needle  is  being  advanced.     This  has 
the  advantage  of  insuring  its  more  uniform  distribution  as  well  as 
avoiding  the  puncture  of  any  small  vessel  which  may  be  encountered. 

It  is  preferable  to  use  a  5  or  10  c.c.  syringe  with  slip- joint  connec- 
tion with  the  needle  so  that  the  syringe  can  be  readily  detached 
for  refilling,  the  needle  remaining  in  situ. 

Having  infiltrated  the  subcutaneous  tissues  the  needle  is  partly 
withdrawn  and  its  point  directed  downward  in  the  midline  toward 
the  rectal  sheath,  which  is  recognized  as  the  first  plane  of  resistance 
which  the  needle  encounters  beneath  the  subcutaneous  tissues;  this 
is  gently  penetrated  at  two  or  three  points  and  the  interval  between 
the  recti  infiltrated.  In  making  these  last  injections  care  should  be 
taken  to  insure  their  being  made  in  the  midline;  if  made  decidedly 
to  one  side  in  the  case  of  a  well-developed  rectal  sheath  it  may  be 
largely  retained  within  the  sheath  and  not  diffuse  sufficiently  to  the 
opposite  side,  resulting  in  an  unsatisfactory  anesthesia. 

Having  infiltrated  the  interval  between  the  recti,  the  needle  is 
advanced  slightly  further  and  the  posterior  sheath  gently  penetrated; 
this  offers  slightly  less  resistance  to  the  needle  than  the  anterior 
sheath.  With  a  knowledge  of  the  anatomy  of  the  part  and  some  ex- 
perience in  injecting  the  different  planes  of  tissue  one  acquires  a 
certain  proficiency  and  knows  with  certainty  the  position  of  the 
needle  point  at  all  times.  For  all  deep  injections  it  is  preferable  to 
use  a  fine  needle  with  a  sharply  beveled  point,  such  as  is  used  for 
spinal  puncture,  rather  than  the  usual  long  tapering  point  which 
has  many  disadvantages  for  this.  work. 

The  degree  of  distention  of  the  bladder  and  general  adiposity 
of  the  individual  influence  the  depth  to  which  the  needle  should 
penetrate  the  posterior  sheath  at  the  different  levels;  should  a  needle 
such  as  is  described  above  enter  the  peritoneal  cavity  no  harm  will 
result,  particularly,  if  the  added  precaution  is  taken  of  always  inject- 
ing the  solution  when  the  needle  is  being  advanced. 

In  the  ordinary  case  with  the  bladder  moderately  distended  I 
usually  make  three  subrectal  injections;  one  3  inches  above  the 
pubes  which  just  penetrates  the  posterior  rectal  sheath,  at  2  inches 
above  the  needle  penetrates  about  ^  inch  beyond  the  sheath,  a  last 
injection  made  just  above  the  pubes  penetrates  about  i  inch  beyond 
the  posterior  rectal  sheath;  about  2  drams  of  solution  is  injected 
at  each  of  the  above  points;  this  completes  the  deep  injections.  If 


GENITOURINARY,  ANORECTAL,  AND   GYNECOLOGIC  OPERATIONS    40! 

any  uncertainty  is  felt  regarding  these  last  deep  injections  they  can 
be  omitted  until  after  the  recti  are  separated  and  the  parts  brought 
into  plainer  view.  Ordinarily,  unless  the  subcutaneous  injection  has 
been  very  free  and  sufficient  time  allowed  for  its  diffusion  outward 
toward  the  skin,  it  will  be  necessary  to  inject  the  skin  which  has  been 
purposely  left  for  the  last;  this  is  done  intradermally  along  the 
proposed  line  of  incision  starting  at  the  wheal  first  produced.  The 
idea  in  making  the  deep  injection  first  and  the  skin  last  is  to  allow 
the  deeper  injections  slightly  longer  time  to  diffuse  and  thoroughly 
saturate  the  surrounding  tissues. 

Operation.— After  the  incision  the  parts  are  gently  retracted 
progressively  advancing  until  the  bladder  is  reached;  the  cellular 
tissue  over  it  is  divided  and  pushed  up  with  the  peritoneum  out  of 
the  danger  zone.  In  making  this  suprapubic  incision,  it  is  advisable 
not  to  approach  too  closely  to  the  pubis,  but  to  keep  i  or  2  inches 
away  from  this  point — the  distance  depending  upon  the  size  of  the 
bladder — and  yet  the  incision  must  not  be  too  close  to  the  peritoneum. 
This  method  has  the  advantage  of  avoiding  the  possible  danger  of 
suppuration  in  this  space  and  facilitates  the  more  rapid  closure  later 
of  the  fistulous  opening,  for  the  nearer  these  openings  are  to  the 
peritoneal  reflection,  the  quicker  seems  to  be  their  closure.  Those 
suprapubic  fistulae  which  have  been  difficult  to  close  have  always  been 
close  to  the  pubes. 

The  superior  bladder  wall  is  not,  as  a  rule,  very  sensitive  but 
it  should  be  lightly  infiltrated  before  being  incised — one  stitch  on 
each  side  fixes  the  upper  part  of  the  bladder  to  the  posterior  rectal 
sheath.  The  bladder  is  then  freely  irrigated  and  its  cavity  explored 
determining  the  size  and  shape  of  the  intravesical  projection  of  the 
prostate,  removing  calculi  should  they  exist,  and  obtaining  any  other 
information  which  may  be  necessary.  If  a  direct  visual  inspection  is 
desired  in  cases  in  which  complications  are  suspected,  this  can  be 
easily  accomplished  by  evacuating  the  contents  of  the  bladder  and  by 
placing  the  patient  in  the  Trendelenburg  position,  air  will  enter  and 
dilate  the  bladder  and  its  interior  can  thus  be  freely  inspected  by 
gently  retracting  the  incision.  Or,  if  preferred,  a  short  proctoscope 
with  light  attached  may  be  passed  within  the  cavity. 

Intravesical  Anesthesia. — If  much  intravesical  examination  is 
necessary,  or  it  is  desirable  to  examine  the  vesical  cavity  digitally, 
some  form  of  intravesical  anesthesia  then  becomes  necessary.  For 
this  purpose  I  have  found  it  both  inadvisable  and  unnecessary,  as 

well  as  ineffective,  to  attempt  to  anesthetize  the  interior  of  the  blad- 

26 


402  LOCAL    ANESTHESIA 

der  for  cystotomy  and  suprapubic  manipulations  within  it  by  filling 
it  a  short  time  before  with  anesthetic  solutions.  This  procedure  is 
now  resorted  to  only  for  cystoscopy.  For  all  manipulations  and 
operations  within  it,  direct  injections  are  made  into,  or  around,  the 
field  to  be  operated. 

The  particular  sensation  with  which  the  bladder  is  endowed  and 
which  is  felt  upon  any  abnormal  contact  with  its  walls,  either  inter- 
nally or  externally,  is  that  feeling  which  we  term  the  desire  to  urinate. 
This  feeling  is  more  easily  excited  by  manipulation  from  within  and 
always  more  acutely  toward  the  vesical  neck  and  prostate  region. 
Pain  is  complained  of  only  when  these  manipulations  have  been 
rough  or  when  actual  trauma  has  been  inflicted.  The  introduction 
of  a  finger  within  the  bladder  for  purposes  of  exploration  excites  a 
desire  to  urinate  and  this  desire  may  become  particularly  urgent  and 
always  becomes  so  when  the  parts  near  the  vesical  neck  are  touched. 
It  is  not  a  pain  but  still  may  be  quite  unbearable  and  demands  some 
effective  method  to  control  it.  This  is  accomplished  in  but  a  few 
moments  of  time.  The  bladder  is  first  well  irrigated  and  then 
emptied;  with  the  patient  in  the  Trendelenburg  position  to  dilate 
the  cavity  and  bring  its  base  into  plain  view,  the  anesthetic  solution 
is  injected  with  a  long,  fine  needle  at  four  or  five  points  around  the 
vesical  neck,  injecting  about  %  dram  at  each  point.  The  needle 
is  advanced  just  through  the  mucous  membrane  with  a  quick  thrust, 
injecting  the  solution  as  the  needle  is  advanced.  Unlike  the  skin 
and  most  other  tissues  the  bladder,  unless  inflamed,  is  tardy  in 
recording  its  sensations  and  anesthesia  results  before  any  sensation  is 
felt  from  the  punctures.  Ordinarily  these  injections  around  the 
vesical  neck  are  sufficient  for  all  intravesical  manipulations,  which 
can  now  be  undertaken  with  the  greatest  freedom.  However,  in 
complicating  conditions  where  the  lateral  walls  are  to  be  operated 
upon,  further  infiltration  around  the  field  becomes  necessary.  But 
as  most  nerves  reach  the  bladder  near  its  base  and  around  the  vesical 
neck,  the  injections  made  here  are  most  effective  in  controlling  its 
sensation. 

If  the  case  is  one  that  does  not  come  within  the  class  requiring 
a  two-stage  operation,  but  the  patient  is  in  fairly  good  physical  con- 
dition with  good  kidneys  and  with  but  little  residual  urine  and  no 
bladder  infection,  the  prostate  may  be  anesthetized  and  removed  at 
once. 

Preparatory  Medication.- — Whether  this  be  done  in  a  one-  or 
two-stage  operation,  certain  preparatory  measures  are  advisable. 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    403 

One  hour  before  operation  a  suppository  containing  10  gr.  of  anes- 
thesin  is  placed  in  the  rectum  to  anesthetize  this  region  and  prevent 
any  discomfort  when  the  finger  is  introduced  here  in  elevating  the 
prostate;  at  the  same  time,  one  hour  before  operation,  a  hypodermic 
of  morphin  %  gr.  and  scopolamin  ^150  gr-  is  administered  to  lessen 
psychical  disturbances. 

Technic  of  the  Second  Stage  Operation. — Infiltration.- — If  the 
case  is  one  in  which  a  cystotomy  has  previously  been  done,  the  Pesser 
catheter  or  tube  is  removed  from  the  suprapubic  opening.  The 
wound  is  found  presenting  a  granular  surface  sloping  down  toward 
the  vesical  opening.  This  is  most  effectively  and  quickly  anesthe- 
tized by  passing  a  fine  needle  through  this  granular  surface  and 
injecting  just  beyond.  By  beginning  these  injections  above,  under 
the  skin  margin,  the  needle  can  be  advanced  obliquely  in  several 
directions,  creating  a  zone  of  anesthesia  just  external  to  this  wall  of 
granulation  tissue,  which  will  diffuse  in  all  directions,  blocking  nerve 
fibers  which  come  into  the  field.  This  is  done  on  both  sides  and 
carried  down  to  the  vesical  opening.  Injections  are  similarly  made 
above  and  below  the  limits  of  the  wound  in  the  subcutaneous  tissues 
in  the  median  line,  as  the  wound  has  probably  contracted  and  will 
have  to  be  enlarged.  The  passage  of  a  fine  needle  through  this 
granular  tissue  causes  no  pain  and  for  that  reason  is  preferred  to 
passing  the  needle  from  the  skin  down.  A  finger  is  passed  into  the 
bladder  to  outline  its  upper  limits  and  determine  the  proximity  of 
the  peritoneal  cavity  above.  Additional  injections  are  now  made 
into  the  upper  wall  of  the  bladder  with  the  finger  within  guiding  the 
point  of  the  needle. 

The  bladder  opening  is  enlarged  and  the  patient  placed  in  a 
moderate  Trendelenburg  position.  After  the  bladder  is  well  irri- 
gated and  emptied,  either  with  a  large  syringe  or  sponges,  its  walls 
are  then  retracted  by  long,  deep  narrow  retractors,  bringing  into 
view  the  field  of  the  prostate.  Depending  upon  the  size  and  shape 
of  the  prostate,  several  points  are  selected  for  injection  on  the  vesical 
surface,  usually  one  below  the  opening  of  the  urethra,  near  the  base 
of  the  gland,  and  one  on  either  side.  The  needle  is  passed  through 
the  mucosa,  with  the  idea  of  making  the  injection  between  the  true 
and  false  sheath  of  the  prostate,  as  it  is  in  this  plane  that  the  solu- 
tion must  diffuse  around  the  gland,  and  it  is  in  this  plane  that  its 
enucleation  is  effected.  It  is  here  where  the  large  venous  plexuses 
are  situated  and  where  the  nerve-filaments  are  more  easily  reached 
as  they  pass  through  to  the  prostate. 


404  LOCAL   ANESTHESIA 

Two  or  3  drams  of  a  0.5  per  cent,  novocain  solution,  containing 
10  minims  of  adrenalin  to  the  ounce,  are  injected  at  each  of  the 
above  points.  The  needle  is  then  passed  into  the  urethral  opening 
and  the  lateral  wall  pierced  first  on  one  side  and  then  on  the  other, 
similar  injections  are  made  at  these  points.  During  these  injections 
the  finger  is  kept  within  the  rectum  to  better  guide  the  passage  of  the 
needle  around  the  prostate  where  its  point  can  be  felt  passing  between 
the  gland  and  its  false  capsule;  it  also  facilitates  these  injections  by 
elevating  or  manipulating  the  gland  and  guards  against  the  penetra- 
tion of  the  false  capsule  by  the  needle. 

If  the  gland  is  very  large,  or  there  is  much  of  a  projection  above 
the  urethral  opening,  an  additional  injection  can  be  made  here. 
Otherwise,  the  above  will  prove  sufficient.  It  is  well  now  to  wait  two 
or  three  minutes  for  the  solution  to  diffuse  and  thorough  anesthesia 
to  be  established  before  beginning  the  enucleation.  While  waiting 
for  the  solution  to  diffuse,  the  action  of  the  adrenalin  is  observed  in 
the  prostate,  which  becomes  quite  pale  and  bloodless. 

Anatomical  Difficulties. — Occasionally  a  case  is  met  with  in  which 
anatomical  difficulties,  such  as  are  encountered  in  a  deep  pelvis  with 
sagging  and  overhanging  bladder-walls,  make  the  exposure  of  the 
prostate  region  difficult  and  requiring  much  manipulation  or  deep 
retraction.  Such  cases  are  best  handled  in  the  following  manner 
without  the  loss  of  time  in  useless  tentative  methods ;  with  moderate 
retraction  of  the  upper  portion  of  the  bladder  walls,  the  long  fine 
needle  is  entered  at  the  upper  edge  of  the  bladder  mucosa  just  back 
of  the  pubis  and  progressively  passing  downward  toward  the  prostate 
an  anesthetic  tract  is  produced  in  much  the  same  manner  as  a  tract 
on  the  skin  is  anesthetized,  this  tract  can  be  made  to  run  over  the 
surface  of  the  prostate  or  pass  just  to  one  side  toward  the  base  as 
preferred. 

The  same  thing  can  be  accomplished  by  passing  the  needle  down 
submucously  injecting  as  it  advanced  until  the  prostate  region  is 
reached.  In  this  way  we  approach  the  prostate  by  an  anesthetic 
pathway  and  easily  reach  the  sensitive  region  at  the  neck  of  the 
bladder  and  the  points  from  which  the  sensibility  of  practically  the 
entire  bladder  can  be  controlled.  The  anesthetic  area  around  the 
vesical  neck  can  be  enlarged  as  required  and  the  deep  injections 
around  the  prostate  made  through  this  anesthetized  area.  The  adop- 
tion of  the  above  method  will  often  be  found  to  solve  the  difficulties 
in  reaching  an  inaccessible  prostate. 

In  making  the  deep  injections,  should  they  be  made  into  the 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS  405 

substance  of  the  gland  itself  no  harm  will  be  done,  only  they  are  not 
quite  as  effective  as  when  injected  peripherally  between  the  true 
and  false  sheath ;  any  excess  of  the  solution  thrown  into  the  gland  in 
this  way  is  removed  during  its  enucleation  and  not  absorbed.  Fol- 
lowing these  injections  a  catheter  is  passed  into  the  bladder.  The 
enucleation  of  the  gland  can  now  be  undertaken  by  any  method  pre- 
ferred by  the  operator  and  will  be  absolutely  free  from  all  pain  or 
other  discomfort.  If  the  intraurethral  method  is  chosen  the  passage 
of  the  catheter  can  be  omitted  until  later,  but  I  have  always  found 
its  presence  a  convenient  guide  to  the  location  of  the  urethra  during 
the  different  stages  of  the  operation. 


Fig.  105. — A,  Gauze  pack  in  position  in  prostatic  wound;  B,  heavy  silk  doubled 
attached  to  pack;  C,  end  of  pack  projecting  from  suprapubic  wound. 

Control  of  Hemorrhage. — A  most  striking  feature  is  the  absence 
of  all  bleeding,  only  a  few  sponges  being  slightly  soiled,  the  loss  of 
blood  amounting  to  not  more  than  i  or  2  drams  at  most.  There  is 
no  blood  to  swab  out  of  the  bladder  afterward. 

The  cavity  left  by  the  prostate  is  now  packed  with  a  Mikulicz 
pack.  This  is  done  in  the  following  manner: 

The  catheter  which  has  been  left  in  the  urethra  is  now  utilized 
to  draw  through  the  urethra,  from  the  bladder  outward,  a  stout  piece 
of  silk  which  has  been  doubled  and  passed  through  a  plug  or  pad  of 
iodoform  gauze  arranged  somewhat  cone-shape  and  about  the  size 
of  the  cavity  left  by  the  removed  gland.  The  silk  thread  is  long 


406  LOCAL   ANESTHESIA 

enough  to  reach  beyond  the  glans  penis  and  when  pulled  upon  draws 
this  plug  effectively  into  the  cavity,  thus  insuring  against  any 
possible  secondary  hemorrhage.  The  plug  in  passing  into  the  cavity 
also  has  the  effect  of  turning  in  any  free  edge  or  shreds  of  mucous 
membrane  against  the  raw  surface  of  the  capsule.  One  end  of  the 
pack  is  left  long  enough  to  protrude  through  the  suprapubic  opening 
to  facilitate  its  removal  later.  The  removal  can  be  simplified  by 
the  method  of  arranging  the  pack ;  a  piece  of  gauze  is  first  folded  into 
a  strip  from  i  to  2  inches  wide,  one  end  is  spread  open  to  make  a 
covering  for  the  remainder  which  is  packed  within  this  outer  por- 
tion in  successive  folds,  one  above  the  other,  the  end  from  the  last 
fold  is  left  long  to  project  from  the  suprapubic  opening.  Held  in 
this  position  each  fold  is  transfixed  by  the  needle  and  thread.  The 
pack  when  in  position  and  arranged  in  this  manner  is  gradually 
unfolded  when  the  suprapubic  end  is  pulled  upon  and  comes  away  as 
a  long  strip  rather  than  en  masse,  thus  making  its  removal  easier  and 
safer. 

This  is  a  most  effective  and  simple  method  of  providing  against 
possible  secondary  hemorrhage,  which  is  impossible  when  the  pack 
has  been  properly  placed.  As  the  pack  is  entirely  under  your  con- 
trol, it  can  be  forced  in  tighter  by  drawing  upon  the  urethral  string, 
or  loosened  by  manipulating  the  suprapubic  end.  For  this  valuable 
procedure  I  am  indebted  to  my  friend  and  teacher,  Prof.  .Matas, 
who  taught  me  its  use  and  advantages. 

A  drainage  tube  placed  in  the  suprapubic  opening  and  a  few 
approximating  sutures  complete  the  operation. 

The  pack  is  removed  in  twenty-four  or  forty-eight  hours  when 
danger  of  hemorrhage  is  past  and  the  case  is  handled  by  the  usual 
methods  following  these  operations. 

Advantages. — A  notable  feature  is  the  absence  of  all  shock  or  de- 
pression, the  pulse  showing  very  little  change  after  operation.  Often 
there  is  not  enough  pain  to  justify  a  hypodermic.  These  cases  are 
usually  up  in  a  chair  in  a  few  days  and  on  their  feet  by  the  end  of  a 
week.  The  nourishment  is  usually  restricted  to  liquids  for  the  first 
day,  after  which  they  are  permitted  to  eat  what  their  appetite  calls 
for.  Many  cases  operated  by  this  method  show  absolutely  no  after- 
disturbance  of  any  kind  and  feel  as  if  they  had  not  been  operated  at 
all.  The  solution  used  for  this  work  should  preferably  be  novocain 
0.5  per  cent,  in  0.4  per  cent,  sodium  chlorid  solution.  Ten  or  15 
drops  of  adrenalin  solution  i  :  1000  are  added  to  3  or  4  ounces  of  the 
solution.  For  the  injections  around  the  prostate  slightly  more 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   407 

adrenalin  may  be  desirable.  I  usually  use  about  10  drops  to  each 
ounce  of  the  anesthetic  solution. 

If  novocain  is  difficult  to  obtain,  as  is  the  case  at  present,  the 
operation  can  be  as  satisfactorily  performed  with  eucain  or  Schleich's 
No.  i  solution  of  cocain. 

Prostatic  abscesses,  when  pointing  toward  the  perineum,  can  be 
opened  under  infiltration.  With  the  finger  in  the  rectum  as  a  guide, 


False  sheath 
offro-s. 


Fig.  106. — Author's  method  for  injecting  prostate:  Lines  1-3  indicate  points  for 
injection  above  and  on  side  of  prostate;  4,  beneath  prostate,  this  may  at  times  be  more 
conveniently  made  by  a  curved  needle;  5,  enters  urethral  opening,  penetrates  urethra, 
and  is  made  between  lobes  of  gland.  While  the  lines  show  the  axis  of  the  injections 
with  the  prostate  lying  normally  in  its  bed  when  the  injections  are  made,  the  prostate 
is  lifted  up  by  a  finger  in  the  rectum,  so  that  the  needle  can  be  more  readily  entered  in 
the  proper  position  through  the  suprapubic  opening. 

the  infiltration  and  dissection  is  advanced  until  the  abscess  is  reached. 
It  is  hardly  necessary  to  block  the  pudic  nerves,  unless  the  abscess  is 
very  deeply  situated. 

A  particularly  favorable  method  of  operating  upon  these  parts  is 
by  parasacral  anesthesia,  as  described  under  that  heading. 

THE  KIDNEY  AND  URETER 

The  free  exposure  and  anesthesia  of  the  kidney,  and  ureter  as 
far  down  as  the  brim  of  the  true  pelvis,  can  be  quite  satisfactorily 


408  LOCAL   ANESTHESIA 

carried  out.  While  several  methods  have  been  suggested,  including 
paravertebral  anesthesia,  the  author  prefers  the  following  plan  as 
easier,  quicker  and  always  certain  of  satisfactory  anesthesia.  The 
only  condition  under  which  it  cannot  be  satisfactorily  undertaken 
is  in  the  presence  of  extensive  perirenal  adhesions,  or  complicating 
surrounding  pathology.  «  Under  such  condition  local  methods  should 
not  be  attempted  alone. 

The  use  of  the  Lillian  thai  bridge,  or  sand -bags,  to  elevate  the 
kidney  region  should  not  be  made  use  of  until  just  at  the  time  the 
kidney  is  ready  to  be  delivered  and  then  used  to  a  less  degree  than 
under  general  anesthesia,  as  they  may  become  very  uncomfortable 
or  even  painful  and  cause  the  patient  to  complain  or  squirm  about 
in  a  trying  way.  After  the  kidney  is  delivered,  these  aids  may  be 
partially  or  entirely  removed  and  it  is  often  found  possible  to  per- 
form the  operation  without  them,  or  a  satisfactory  substitute  may  be 
had  in  a  soft  pillow  doubled  up  under  the  lumbar  region.  With 
the  patient  in  a  comfortable  position,  a  point  midway  between  the 
last  rib  and  crest  of  the  ilium  along  the  proposed  line  of  incision  is 
selected  and  an  intradermal  wheal  created.  A  large  syringe  and 
long  needle  are  now  used;  0.25  per  cent,  novocain  or  0.20  per  cent, 
eucain  solution  will  be  found  amply  sufficient.  The  long  needle  is 
entered  through  the  wheal  and  directed  up  subcutaneously  over  the 
last  rib,  injecting  as  the  syringe  is  advanced  as  far  as  the  eleventh 
rib.  The  point  is  now  slightly  withdrawn  and  directed  close  under 
the  lip  of  the  rib  and  an  injection  made  here  to  reach  the  eleventh 
intercostal  nerve.  The  needle  is  now  withdrawn  almost  the  entire 
length  and  redirected  on  a  slightly  deeper  plane — always  injecting 
the  solution  as  the  needle  is  being  advanced,  removing  the  syringe 
from  time  to  time  for  refilling.  The  needle  is  now  advanced  in 
contact  with  the  twelfth  rib.  The  twelfth  intercostal  nerve,  unlike 
the  other  intercostals,  leaves  the  rib  early  in  its  course  running  ob- 
liquely away  from  it  downward  and  forward,  and  in  the  position 
encountered  here  about  3  inches  from  the  spine,  it  lies  from  ^  to  i 
inch  away  from  the  rib.  As  the  needle  passes  this  point,  a  slightly 
larger  quantity  of  solution  is  injected.  The  needle  is  now  almost 
withdrawn  and  redirected  down  close  in  contact  with  the  sheath  of 
the  quadratus  lumborum  and  advanced  up  along  it  for  several 
inches,  distributing  the  solution.  By  changing  the  direction  of  the 
needle,  the  aponeurosis  of  the  abdominal  muscles  at  the  point  where 
they  fuse  with  the  sheath  of  the  quadratus  lumborum,  is  sought  for: 
this  is  about  2  to  2^  inches  from  the  lumbar  spinous  processes. " 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS  409 

This  is  recognized  as  the  first  plane  of  resistance  which  the  needle 
encounters.  It  is  penetrated  at  several  points  and  a  few  drams  of 
solution  deposited  beneath  it.  The  needle  is  now  directed  slightly 
deeper  into  the  perirenal  fat  and  about  ^  ounce  of  solution  deposited 
here  extending  as  high  as  a  point  well  up  under  the  last  rib.  If 
any  uncertainty  is  felt  in  making  these  last  deep  injections,  they  can 
be  omitted  until  the  aponeurosis  of  the  muscles  is  exposed  and  the 
deeper  parts  of  the  field  brought  closer  within  reach. 

Having  completed  the  above,  the  lower  half  of  the  field  is  now 
injected  in  a  similar  manner  by  directing  the  needle  downward  from 
the  skin  wheal  toward  the  crest  of  the  ilium,  but  on  a  slightly  anterior 
plane  approaching  the  anterior  portion  of  the  iliac  crest  to  conform 
to  the  curve  of  the  proposed  incision. 

The  tissues  here  are  injected  in  several  planes  as  above — the 
first  injection  being  made  subcutaneously.  When  proceeding  by  this 
method,  it  is  unnecessary  to  inject  the  skin  independently,  as  the 
subcutaneous  injection  has  ample  time  to  diffuse  outward  while 
making  the  deeper  ones.  The  operation  can  now  be  proceeded  with 
and  as  it  will  usually  be  found  advisable  to  resect  the  twelfth  rib, 
this  is  done  at  once  and  furnishes  ample  room  for  access  to  the  parts 
beneath  without  undue  traction. 

A  limited  amount  of  injecting  in  the  deeper  parts  will  now  be 
all  that  is  needed.  The  advantage  of  practically  completing  the 
injection  before  making  the  incision  is  obvious.  With  the  weak 
solution  employed  ample  time  is  allowed  for  thorough  saturation  of 
the  tissues  and  only  the  excess  escapes  when  the  incision  is  made. 
It  is  also  much  quicker  and  by  following  a  methodical  plan  of  this 
kind,  no  portion  of  the  field  is  left  uninjected. 

After  dividing  the  aponeurosis  of  the  abdominal  muscles  the 
twelfth  dorsal  nerve,  a  large  branch,  is  encountered  between  their 
planes,  giving  off  in  this  position  its  lateral  cutaneous  branch. 

By  gently  following  these  two  trunks  proximately  they  are  seen 
to  approach  each  other  and  join  on  the  anterior  surface  of  the 
quadratus  lumborum  in  the  depth  of  the  wound,  they  can  now  be 
injected  intraneurally  which  should  be  done  as  deep  down  as  they 
can  be  conveniently  reached.  They  are  the  principal  sensory  nerves 
of  the  superficial  parts  and  their  thorough  anesthesia  insures  a 
painless  wound. 

Having  freely  divided  the  aponeurosis  of  the  abdominal  muscles, 
the  finger  is  gently  passed  inward  through  the  cellular  tissue  along  the 
anterior  surface  of  the  quadratus  lumborum  muscle;  this  tissue  is 


410  LOCAL   ANESTHESIA 

loose  and  easily  separated,  searching  the  way  for  the  needle  which  is 
now  advanced  in  this  direction  toward  the  vertebral  column  and  a 
few  drams  of  solution  deposited  here  in  the  tissues  underlying  the 
hilum  of  the  kidney.  If  the  kidney  is  adherent,  this  injection 
should  be  more  liberal  than  in  a  simple  case  and  should  be  carried 
well  in  toward  the  psoas  muscle  which  is  easily  felt  and  can  be  seen 
with  retraction  of  the  tissues.  This  deep  injection  is  very  easily 
made  and  is  of  much  importance  should  the  kidney  be  adherent  or 
the  abdominal  cavity  likely  to  be  opened,  as  it  controls  the  entire 
nerve-supply  of  this  portion  of  the  cavity  by  blocking  the  sensory 
fibers  of  the  rami  communicantes  which  run  in  the  sympathetic 
chain  on  each  side  of  the  vertebral  column. 

This  completes  the  anesthesia  and  no  further  steps  of  the  opera- 
tion need  be  explained  here,  as  it  can  now  be  performed  by  any  tech- 
nic  preferred,  but  where  the  kidney  is  to  be  removed,  I  usually  make 
a  slight  additional  injection  along  the  vessels  at  its  hilum  after 
the  organ  is  exposed  and  before  separating  them  from  the  ureter, 
but  this  injection  is  unnecessary  if  the  injections  close  to  vertebral 
column  have  been  ample. 

By  following  this  method  of  procedure,  which  is  the  gradual 
evolution  of  much  clinical  experience,  1  have  frequently  removed 
kidneys  or  freely  opened  them  along  their  entire  length  down  to  the 
pelvis  in  removing  calculi.  In  one  case  of  polycystic  kidney,  which 
was  considerably  larger  than  a  man's  head,  filling  the  entire  right 
side  of  the  abdominal  cavity  and  badly  adherent,  the  organ  was 
separated  from  its  adhesions  and  the  cysts  ruptured,  reducing  the  kid- 
ney to  about  normal  size,  without  any  discomfort  on  the  part  of 
the  patient. 

The  thorough  anesthesia  of  the  field  which  permits  such  muscular 
relaxation  often  makes  the  use  of  retractors  superfluous  and  the  use 
of  kidney  pads  of  the  Lillianthal  bridge  unnecessary. 

Operations  upon  the  ureter  are  similarly  performed,  omitting 
the  deep  anesthesia  .toward  the  vertebral  column  and  anesthetizing 
only  the  cellular  tissue  along  the  recognized  course  of  this  organ. 
By  carrying  this  anesthesia  to  a  lower  level  and  dividing  the  abdom- 
inal muscles  at  their  attachment  to  the  iliac  crest,  the  ureter  can  be 
easily  followed  as  far  down  as  the  brim  of  the  true  pelvis.  Beyond 
this  point  local  methods  are  not  feasible.  As  the  ureter  descends, 
it  approaches  the  peritoneum  and  is  adherent  to  it  throughout  the 
lower  part  of  its  course  and  is  easily  found  in  this  position  as  these 
tissues  are  separated  from  the  posterior  abominal  wall.  High  up  in 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   411 

its  course,  the  ureter  is  best  located  by  following  it  down  from  the 
kidney. 

Perinephritis  abscess  requires  no  special  technic,  but  can  be 
readily  opened  by  infiltrating  the  several  planes  of  tissue  which 
overlie  it.  As  any  pressure  excites  pain,  the  infiltrating  should  be 
gently  and  slowly  proceeded  with,  using  slightly  stronger  solutions 
than  advocated  above,  at  least  0.50  per  cent,  novocain. 

ANORECTAL  REGION 

Any  of  the  many  affections  involving  the  easily  accessible  parts 
of  this  region  may  be  quite  satisfactorily  operated  upon  by  local 
anesthesia,  provided  the  procedure  is  not  too  complicated;  where  this 
is  the  case,  as  in  extirpation  of  the  rectum,  parasacral  or  epidural 
anesthesia  should  be  resorted  to. 

The  region  of  distribution  of  the  pubic  nerve  may,  in  many  re- 
spects, be  compared  to  that  of  the  fifth  nerve,  the  two  most  sensitive 
areas  in  the  body.  The  disturbances  arising  from  disease  of  these 
parts  are  often  considerable  and  out  of  all  proportion  to  the  size  of  the 
lesion  if  situated  elsewhere;  their  reflexes  are  numerous  and  varied, 
and  often  involve  remote  parts  of  the  body. 

In  the  rectum  the  sensitive  area  is  practically  limited  to  the 
terminal  2  inches  of  the  bowel  or  anal  canal.  Above  this  point 
there  is  very  little  sensation.  It  is  in  this  terminal  2  inches  that 
disease  is  most  frequently  encountered — in  fact,  more  often  than  in 
all  the  rest  of  the  alimentary  canal.  When  we  consider  the  nature 
of  these  affections,  we  are  forced  to  the  conclusion  that  the  great 
majority  of  them  may  be  claimed  by  the  domain  of  local  anesthesia, 
reserving  a  few  of  the  most  serious  operations,  such  as  extensive  resec- 
tions, for  general  narcosis;  these,  however,  are  a  small  percentage  of 
the  operations  performed  in  this  region.  Persons  affected  with 
anorectal  disease  are,  as  a  rule,  more  nervous  and  apprehensive, 
and  for  this  reason  the  preliminary  hypodermic  of  morphin,  ^  gr., 
scopolamin,  3^50  gr->  recommended  elsewhere  for  all  major  opera- 
tions, should  not  be  omitted  here. 

All  operations  under  local  anesthesia  in  this  highly  sensitive 
region  have  to  be  performed  with  great  care,  and  the  technic  of  any 
method  of  anesthesia  employed  carried  out  with  exactness  and  thor- 
oughness to  insure  success;  the  solutions  need  not  be  of  any  greater 
strength  than  those  used  elsewhere  (0.25  per  cent,  novocain  for  infil- 
tration and  0.50  per  cent,  for  nerve  blocking,  with  the  addition  of  the 


412 


LOCAL   ANESTHESIA 


usual  amount  of  adrenalin),  though  stronger  solutions  may  sometimes 
be  necessary. 

Reclus,  in  1889,  was  the  first  to  satisfactorily  anesthetize  this 
region  to  permit  the  painless  dilatation  of  the  anus.  He  used  i  to 
2  per  cent,  solutions  of  cocain.  He  was  followed  by  Schleich  in  1894, 
and  the  methods  of  infiltration  used  in  this  region  to-day  are  largely 
the  same  as  those  advocated  by  these  two  pioneers  in  the  field  of 
local  anesthesia. 

The  nerves  of  this  region  are  practically  the  same  as  those  de- 
scribed for  the  geni to-urinary  organs,  and,  when  preferred,  the  pudic 


Fig.  107. — Method  of  making  paraneural  injection  around  pudic  nerve.  The  long 
needle  is  entered  at  an  anesthetized  point  about  i)^  inches  back  of  rectum.  The  finger 
in  the  rectum  locates  the  spine  of  the  ischium  and  guides  the  advancing  needle.  The 
injection  is  slowly  made  as  the  needle  is  advanced  to  about  J£  inch  to  the  inner  side  and 
slightly  in  front  of  the  base  of  the  tuberosity  of  the  ischium. 

nerve  can  be  blocked  in  the  same  way  near  the  spine  of  the  ischium 
(Fig.  107),  and  if  the  operative  field  extends  some  distance  behind 
and  to  the  side  of  the  rectum,  as  in  fistula,  the  inferior  pudendal  will 
also  have  to  be  blocked  on  the  outer  side  of  the  ischium;  both  proced- 
ures are  discussed  under  the  above  heading.  When  used,  this  method 
should  be  combined  with  a  thorough  perianal  infiltration  in  the 
same  way  as  described  later. 

This  procedure,  while  used  by  some  operators,  is  not  very  popular, 
as  it  often  fails  to  produce  a  satisfactory  surgical  anesthesia,  due  to 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    413 

the  uncertainty  of  accurately  reaching  the  nerve  at  the  point  of 
injection. 

The  following  method  is  much  to  be  preferred,  being  simpler, 
quickly  executed,  and  absolutely  reliable  in  producing  a  perfect  sur- 
gical anesthesia. 

This  technic  is  so  simple  and  quickly  executed  that  the  writer 
almost  invariably  uses  it  for  all  operations  in  this  region  (hemor- 
rhoids, fissure,  prolapse,  etc.)  in  preference  to  a  general  anesthesia. 


Fig.  108. — Points   of   injection  for  surrounding  anal  canal  with  zone  of  anesthesia. 

(From  Braun.) 

The  tissues  are  first  infiltrated  subcutaneously  around  the  anus 
at  the  mucocutancous  junction,  as  seen  in  Fig.  108.  It  is  better  to 
start  the  injection  an  inch  or  more  away  in  the  less  sensitive  skin, 
and  advance  toward  this  region,  when  the  injection  is  then  carried 
out  circumferentially,  rather  than  to  make  the  first  puncture  in  this 
area,  which  is  highly  sensitive,  and  will  always  excite  some 'complaint, 
and  in  nervous  patients  cause  them  to  become  uneasy  and  lose  con- 
fidence in  the  promise  of  a  painless  operation.  The  author  always 
uses  an  ethyl  chlorid  spray  on  the  skin  at  the  point  of  puncture,  first 


414 


LOCAL   ANESTHESIA 


Fig.  109. — Method  of  making  subcutaneous  injection  around  anus.     Patient  in  Sims' 

position. 


Fig.  no. — Method  of  making  deep  perirectal  injections. 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   415 


thoroughly  protecting  the  anus  against  any  contact  with  the  spray 
by  holding  a  gauze  sponge  well  against  it. 


-^Sphincter  muscle 


Fig.  in. — Schematic  representation  of  method  of  producing  anesthesia  of  anal  canal. 
(Taken  from  Braun,  slightly  modified.) 

The  circumferential  injection  is  made  subcutaneously,  as  the 
skin  and  mucous  membrane  at  their  point  of  junction  are  very  thin, 
and  an  intradermal  injection  difficult  and  not  at  all  essential. 


'• 


\. 


Fig.  112. — Method  of  dilating  rectum  with  hand  in  cone  shape. 

By  drawing  out  the  skin  of  this  region  with  one  hand  the  tissues 
are  put  upon  the  stretch,  and  all  folds  and  creases  obliterated  (Fig. 
109),  making  it  less  likely  to  transfix  a  fold  causing  pain;  the  solution 
is  injected  as  the  needle  is  advanced;  for  each  re-insertion  of  the 


416 


LOCAL   ANESTHESIA 


needle  starting  just  back  of  the  point  where  the  needle  last  stopped; 
having  completed  the  circumferential  injection,  a  finger  is  now 
passed  within  the  rectum  as  a  guide,  and  the  large  syringe  and  long 
needle  used;  the  needle  is  passed  through  the  anesthetized  area  of 
skin  and  directed  up  the  bowel,  just  outside  of  the  sphincters,  in- 
jecting, as  the  needle  is  advanced,  to  a  depth  of  about  2%  or  3 
inches  (Fig.  no);  four  points  are  injected;  one  on  each  side,  injecting 
in  each  of  these  about  10  c.c.,  and  one  in  front  and  behind  the  bowel, 
injecting  in  each  of  these  about  5  c.c.  • 


Fig.  113. — Method  of  anesthetizing  fistulous  tract.     (From  Braun.) 

Anesthesia  results  almost  immediately,  at  most  after  a  delay  of  a 
few  minutes,  when  dilatation  may  be  begun  and  can  be  as  thoroughly 
carried  out  as-  under  a  general  anesthetic. 

A  graphic  illustration  of  the  method  of  making  these  injections 
is  shown  in  Fig.  in.  The  author  always  prefers  to  use  the  hand  as 
a  dilating  medium,  which  is  less  likely  to  tear  or  lacerate  the  parts, 
using  soap  as  the  lubricating  medium;  first  one  finger  is  passed,  then 
two  and  three,  and,  finally,  the  whole  hand  in  a  cone-shape  is  rotated 
around  in  a  screw-like  fashion  (Fig.  112)  until  dilatation  is  complete. 
This  is  the  method  always  used  by  Prof.  Matas  for  dilatation  and  is 
superior  to  any  other. 

Braun  instead  of  making  these  deep  injections  just  outside  the 


GENITO-URINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   417 

bowel  wall  makes  them  submucously  between  the  mucous  mem- 
brane and  the  sphincters,  the  amount  of  solution  used  and  the  depth 
of  the  injections  is  about  the  same.  This  method  is  simpler  and 
easier  for  the  inexperienced.  The  subsequent  manipulations  for 
dilatation  serve  to  thoroughly  diffuse  the  anesthetic. 

In  operations  for  fistula,  in  addition  to  the  above  method  of 
anesthesia,  which  anesthetizes  the  anal  canal  and  permits  dilatation, 
the  fistulous  tract  must  also  be  anesthetized  by  injections  made  on 
each  side  and  beneath  it,  so  as  to  thoroughly  embrace  it  within  a 
wall  of  anesthesia.  The  method  of  making  these  injections  is 
illustrated  in  Fig.  113.  The  fistulous  tract  can  then  be  slit  up, 
excised,  or  curetted  as  preferred. 

For  methods  of  infiltration  it  is  well  to  precede  the  injections  in 
badly  inflamed  or  sensitive  cases  by  placing  a  pledget  of  cotton 
saturated  with  5  or  10  per  cent,  novocain  solution  within  the  anal 
canal,  and  allow  it  to  remain  while  injecting  elsewhere;  in  this  way 
the  canal  will  permit  the  painless  introduction  of  the  finger  to  guide 
the  needle  in  the  deep  infiltration. 

In  the  original  method,  first  advocated  by  Reclus  and  Schleich, 
the  infiltration  was  made  directly  into  the  substance  of  the  sphincters, 
but  this  is  not  necessary,  and  it  would  seem  advisable  to  infiltrate  the 
loose  cellular  tissue  surrounding  the  bowel  rather  than  the  muscle 
itself.  When  the  above  technic  has  been  well  carried  out  it  is  not 
necessary  to  infiltrate  the  mucosa ;  this  is  then,  consequently,  a  para- 
neural  regional  anesthesia.  By  the  above  technic  any  of  the  ordinary 
operative  procedures  for  hemorrhoids,  fistula,  polypi,  ulcers,  fissure, 
or  resection  of  the  rectal  mucosa  for  prolapse  may  be  quite  satis- 
factorily and  painlessly  performed.  In  many  operations  upon  this 
region  it  is  not  necessary  to  dilate  the  sphincter.  While  this  is 
desirable  in  all  operations  of  any  magnitude  to  paralyze  the  muscles 
and  permit  free  inspection  and  access  to  the  anal  canal,  there  are 
many  cases  of  sentinel  piles  and  other  superficially  situated  lesions, 
as  fissures,  where  this  practice  may  be  dispensed  with  and  the 
lesions  dealt  with  by  simple  infiltration.  This  is  particularly  suited 
to  office  practice,  where  many  of  the  minor  affections  of  these  parts 
may  be  operated  upon. 

In  operations  for  fissure,  while  it  is  always  desirable  to  stretch 
the  sphincter,  this  procedure  alone  often  sufficing  for  a  cure  in  super- 
ficial lesions,  it  is  not  absolutely  necessary.  With  the  proper  care 
and  delicacy  in  manipulation  these  cases  can  often  be  operated  in 
the  office  or  at  the  patient's  home  with  satisfactory  results.  The 


418  LOCAL   ANESTHESIA 

needle  is  entered  in  healthy  tissue,  just  below  the  lesion,  and  infil- 
tration gently  carried  out,  advancing  the  needle  under  the  fissure 
in  the  substance  of  the  sphincter,  infiltrating  gently  as  it  is  advanced, 
until  the  entire  underlying  area  is  well  infiltrated ;  the  finger  will  then 
be  quite  easily  tolerated  in  the  rectum,  and  the  extent  of  the  lesion 
well  explored. 

A  blunt-pointed  bistoury  is  now  advanced  on  the  flat  against  the 
finger  until  the  upper  part  of  the  area  is  reached,  then  turned  edge 
down,  and  the  fibers  of  the  sphincter  at  the  base  of  the  fissure  incised 
to  a  depth  of  about  y±  inch.  This  may  be  done  at  one  point  in  the 
middle  or  on  each  side,  and  effectually  puts  the  muscle-fiber  at  rest 
and  permits  the  ulcer  to  heal;  it  is  then  dressed  with  ichthyol  and 
anesthesin  ointment,  15  or  20  per  cent,  of  each. 

In  performing  the  operation  this  way,  care  should  be  exercised 
not  to  incise  too  far  up  the  bowel  or  too  deeply  for  fear  of  opening 
some  small  artery,  which  may  give  rise  to  an  unpleasant  hemor- 
rhage; it  is  only  in  that  portion  of  the  canal  surrounded  by  the 
external  sphincter  that  the  incision  should  be  made;  more  extensive 
ulcerations,  extending  up  the  bowel,  should  not  be  treated  this 
way.  Malignant  disease  of  these  parts  unless  quite  limited,  super- 
ficially situated,  and  of  easy  access  should  be  reserved  for  para- 
sacral,  epidural,  spinal,  or  general  anesthesia.  Perirectal  and  ischio- 
rectal  abscess  if  superficial  may  be  easily  opened  by  infiltration.  In 
the  case  of  the  former,  where  it  is  desirable  to  dilate  or  divide  the 
sphincter,  one  of  the  above-mentioned  methods  should  be  used  to 
secure  anesthesia. 

The  use  of  sterile  water  as  an  anesthetic  agent  when  injected 
into  the  tissues  has  long  been  known,  and  its  application  to  surgery 
of  these  parts  has  frequently  been  tested;  Dr.  S.  G.  Gant,  of  New 
York,  is  particularly  enthusiastic  in  its  use,  and  has  done  much  to 
popularize  it  here.  For  hemorrhoids  or  fistula  operations  of  limited 
extent  the  anesthesia  is  quite  satisfactory,  but  it  is  not  suited  for 
extensive  operations  where  the  deep  parts  are  involved.  The  objec- 
tion to  its  use  is  the  burning  pain  produced  by  the  infiltration;  this, 
while  greater  in  some  cases  than  others,  is  often  quite  severe,  and  is 
not  a  negligible  factor  in  considering  this  form  of  anesthesia.  The 
pain  in  making  these  injections  is  much  lessened  if  the  injection  is 
very  slowly  made,  so  as  not  to  distend  the  tissues  too  rapidly;  by  the 
addition  of  a  small  quantity  of  cocain  or  novocain,  o.i  per  cent.,  this 
infiltration  pain  is  entirely  relieved;  this,  however,  is  no  longer  pure- 


GENITO-URINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    419 

water  anesthesia.  For  a  further  consideration  of  water  anesthesia 
(anesthesia  dolorosa),  see  chapter  on  this  subject. 

The  use  of  ethyl  chlorid  about  the  anus  is  rather  unsatisfactory, 
as  it  often  produces  considerable  burning,  but  for  superficial  incisions 
in  areas  removed  from  the  anal  margin,  or  where  this  can  be  protected, 
it  is  often  quite  satisfactory. 

Before  dismissing  this  subject  reference  should  be  made  to  the 
use  of  quinin  and  urea,  which  are  applicable  for  the  surgical  treat- 
ment of  a  limited  number  of  rectal  affections,  and  the  reader  is 
referred  to  the  chapter  on  this  subject. 

The  topical  application  of  the  various  analgesic  and  anesthetic 
preparations  is  often  of  great  value  here  for  the  palliative  relief  of  the 
inflammatory  affections  of  these  parts,  such  as  hemorrhoids,  fissures, 
ulcers,  etc.  Anesthesin  has  largely  replaced  the  use  of  antipyrin  and 
orthoform,  as  it  is  a  more  active  agent,  and,  in  view  of  its  slow  solu- 
bility, maintains  this  action  for  a  long  time;  it  is  also  practically  non- 
toxic,  even  in  concentrated  solutions  (10  to  15  gr.  can  be  safely 
administered  internally  at  a  time) .  It  is  best  used  in  ointment  form 
in  10  and  20  per  cent,  strengths.  Combined  with  other  astringent 
and  sedative  drugs  (adrenalin,  hemamelis,  belladonna,  etc.),  in  this 
form  its  application  externally  or  to  the  anal  canal  with  a  pile-pipe 
or  by  suppository  often  affords  gratifying  relief  in  many  painful 
affections.  Cocain,  novocain,  alypin,  etc.,  when  used  in  a  similar 
way,  have  to  be  frequently  repeated,  and  may  prove  dangerous 
from  their  rapid  solubility  if  used  in  concentration  or,  if  long  con- 
tinued, may  encourage  a  habit,  and  for  these  reasons  are  rarely 
employed  in  this  way. 

Operative  procedure  under  the  topical  application  of  pure  carbolic 
acid,  while  practical  for  limited  procedures  involving  nothing  more 
than  a  superficial  incision,  is  rather  unsurgical,  and  is  not  to  be  recom- 
mended for  more  than  an  incision  such  as  would  be  needed  for  turning 
out  the  clot  in  a  thrombotic  hemorrhoid  or  opening  a  superficial  ab- 
scess; it  can  also  be  made  use  of  for  anesthetizing  a  small  point  to 
permit  the  painless  introduction  of  the  hypodermic  needle.  When 
used  for  anesthesia  the  surface  upon  which  it  is  applied  should  be 
perfectly  dry,  and  after  allowing  it  to  remain  a  few  minutes  the 
excess  is  wiped  off. 

As  a  postoperative  application  the  topical  use  of  one  or  more  of 
the  various  sedative  and  analgesic  preparations  is  often  of  great 
value  in  allaying  the  after-pain  and  burning  common  to  most  opera- 
tions upon  these  parts,  particularly  hemorrhoids,  where  the  cautery 


420  LOCAL    ANESTHESIA 

has  been  used.  Dr.  James  P.  Tuttle  claims  for  sodium  bicarbonate 
a  sedative  action  superior  to  anything  else;  he  says  for  this  purpose 
it  is  incomparable;  it  has  no  analgesic  action  under  other  conditions. 
Following  other  operations  the  immediate  free  use  as  a  primary  dress- 
ing of  a  10  or  15  per  cent,  ointment  of  anesthesin  or  orthoform  will 
be  found  to  greatly  lessen  the  postoperative  discomfort  as  the 
anesthesia  passes  off. 

For  the  non-operative  or  palliative  treatment  of  chronic  tubercu- 
lous, syphilitic,  or  cancerous  ulcers,  anesthesin,  orthoform,  or  car- 
bolic acid  in  ointment  form  prove  effective  analgesic  applications. 
A  quite  satisfactory  treatment  for  fissures,  one  of  the  most  painful 
of  rectal  conditions,  is  by  tampons  soaked  in  ichthyol  and  freely 
sprinkled  with  anesthesin,  such  applications  giving  relief  often  for 
many  hours;  the  same  may  be  said  of  quinin  and  urea  used  in 
ointment  form. 

Much  of  the  after-pain  from  rectal  operations  is  due  to  spasm  of 
the  sphincters,  and  when  opiates  are  used  for  this  purpose  it  may  take 
unsafe  doses  to  control  it;  better  agents  are  chloral  and  bromids 
(per  orem) ,  which  are  often  more  effective  and  safer,  used  in  conjunc- 
tion with  an  anesthesin  ointment.  For  the  chronic  aching  or  neu- 
ralgic pain  of  this  region  a  satisfactory  combination  is  antipyrin, 
acetanilid,  and  codein  administered  internally. 

GYNECOLOGIC  OPERATIONS 

The  surgery  of  the  female  generative  organs  forms  a  large  part 
of  the  operative  work  of  the  present  time.  Much  of  this  work  on 
the  external  and  readily  accessible  parts  may  be  quite  easily  and 
satisfactorily  performed  under  local  methods  of  anesthesia,  and 
even  some  of  the  more  complicated  procedures  on  the  deeper  parts 
may,  with  skill  and  gentleness,  be  painlessly,  or  almost  painlessly, 
accomplished  in  suitable  subjects. 

Women,  as  a  rule,  are  more  apprehensive  and  fearful  than  men, 
and  often  so  extremely  nervous,  particularly  when  having  suffered 
long  from  their  various  affections,  that  they  make  poor  subjects 
for  any  form  of  local  anesthesia.  Many  prefer  to  take  a  general 
anesthetic,  and  be  treated  as  if  they  were  really  not  there  at  all. 
It  is,  accordingly,  advisable  with  the  timorous  and  fearful  not  to 
attempt  any  but  the  simpler  operations  on  the  exposed  parts  by 
local  anesthesia,  reserving  all  complicated  procedures  for  parasacral, 
epidural,  spinal,  or  general  narcosis.  However,  in  the  presence 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    421 

of  centra-indications  to  general  anesthesia,  and  with  positive  indi- 
cations for  operative  interventions,  many  of  the  more  complicated 
procedures  may  be  safely  and  satisfactorily  performed  by  the  skilful 
use  of  local  measures  alone,  or  in  combination  with  light  superficial 
anesthesia  for  the  more  painful  and  deeper  parts.  (See  chapter  on 
Combined  Methods  of  Anesthesia.) 


Sphincter  ani  exlrrnus 
medial  inferior  cluntnl  nerve 
inferior  liaemorrhoidal  a, 
internal  pudic  ves 
Olntneus  maxim 


anococcygeal  nenes       anommeeal  tig. 


Fig.  114. — The  nerves  and  vessels  of  the  female  perineum.  Upon  the  right  side  the 
bulbocavernosus  has  been  partly  removed  and  the  vestibular  bulb  exposed,  the  trans- 
versus  perinei  superficialis  divided,  and  the  urogenital  diaphragm  incised.  |c*  =  The 
origin  of  the  internal  pudic  vein  from  the  vestibular  bulb  (vena  bulbi  vestibuli).  (So- 
botta  and  McMurrich.) 


In  nervous  and  sensitive  patients  care  should  be  taken  to  always 
administer  one  hour  before  operation  a  preliminary  or  preparatory 
hypodermic  of  morphin,  %  to  %  gr.,  with  scopolamin,  ^IQQ  gr->  as 
recommended  in  the  preceding  part  of  this  volume.  It  is  also  well  to 
have  a  sympathetic  nurse  stand  by  the  patient  and  hold  her  hand  or 
encourage  her  if  she  is  uneasy.  For  a  consideration  of  the  nerve-sup- 


422  LOCAL   ANESTHESIA 

ply  of  this  region  see  Fig.  114,  and  for  description  and  methods  of 
blocking  same  see  section  on  Genito-urinary  Organs. 

In  all  the  external  parts  and  lower  2  or  3  inches  of  the  vaginal 
tract  sensation  is  very  acute,  but  the  vault  and  upper  parts  of  the 
vagina  have  very  little  sensation.  The  cervix  and  uterus  are 
not  very  sensitive  to  incisions — volsellum,  forceps,  or  needle  punc- 
tures— but  are  quite  sensitive  to  stretching,  as  in  dilatation  of  the 
cervix.  Also,  the  mucosa  of  the  cervix  and  uterine  cavity  has  very 
little  sensation,  but  will  not  stand  a  thorough  curettage  without 
anesthesia.  The  same  may  be  said  of  the  peritoneal  investment  of 
the  uterus,  which  should  not  be  operated  upon  without  some 
infiltration. 

Solution  No.  2,  0.50  per  cent,  novocain,  is  used  in  all  operations 
upon  the  external  parts,  which  are  highly  sensitive.  Solution  No.  i, 
0.25  per  cent.,  is  ample  for  the  deeper  infiltrations,  but  if  preferred 
No.  2  can  be  used  throughout. 

To  each  solution  add  from  5  to  10  drops  of  adrenalin,  i :  1000  to 
3  or  4  ounces,  if  the  field  is  extensive  and  much  solution  will  likely  be 
injected,  using  the  smaller  quantity  of  adrenalin. 

The  Perineum  and  Postvaginal  Wall. — A  point  on  the  perineum 
midway  between  the  anus  and  vaginal  outlet  is  anesthetised  intra- 
dermally;  establishing  here  a  station  through  which  the  long  needle 
is  entered,  in  the  event  of  an  extensive  laceration  up  to  or  including 
the  sphincter  ani,  this  point  can  be  made  just  within  the  vaginal 
outlet. 

The  long  needle  is  entered  here  and  passed  up  in  the  middle  line, 
injecting  as  it  is  advanced  as  far  as  the  contemplated  field  of  opera- 
tion,  using  often  as  much  as  5  or  10  c.c.;  a  finger  can  be  used  either  in 
the  vagina  or  rectum  as  a  guide.  If  the  plane  of  tissue  is  quite  thick 
it  is  best  to  pass  the  needle  well  below  the  vaginal  mucosa  in  the 
deeper  planes,  as  the  solution  can  better  diffuse  in  these  deeper  layers, 
but  when  dealing  with  an  extensive  laceration  with  rectocele,  where 
the  rectum  and  vaginal  mucosa  are  in  close  contact,  the  needle  had 
best  be  passed  just  beneath  the  vaginal  mucosa,  and  here  the  finger 
is  kept  in  the  bowel  as  a  guide.  By  injecting  the  solution  as  the 
needle  is  advanced,  the  solution  separates  the  plane  of  tissues  and 
there  is  less  danger  of  the  needle  puncturing  the  rectum. 

Having  made  the  midline  injection,  the  needle  is  partially  with- 
drawn and  directed  slightly  laterally  and  upward  on  first  one  side 
and  then  the  other,  using  in  each  an  additional  5  or  10  c.c.,  depending 
upon  the  extent  of  the  field.  Similarly,  a  third  or  fourth  injection 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS    423 

can  be  made  just  lateral  to  the  preceding,  until  practically  the  entire 
vaginal  canal  except  the  roof  has  been  infiltrated.  A  crescentic-like 
injection,  made  subcutaneously  with  the  long  needle  around  the 
vaginal  outlet  and  carried  upon  each  side  the  full  extent  of  the  field, 
completes  the  anesthetizing  process. 

If  a  perineorrhaphy  is  to  be  done,  and  the  tear  involves  the  sphinc- 
ter, the  anal  canal  must  then  be  anesthetized,  as  described  in  that  sec- 
tion. The  above  method  of  injection  gives  a  perfect  anesthesia  and 
is  very  quickly  done  after  a  little  practice,  and  the  latter  steps  of  the 


Fig.  115. — For  anesthesia  of  vaginal  outlet,  including  labia  majora.     (From  Braun.) 

operation,  if  for  perineorrhaphy,  much  facilitated  through  the  sepa- 
ration of  the  different  planes  of  tissues  by  the  injected  solution. 

To  Anesthetize  the  Entire  Vaginal  Outlet. — This  is  done  by  a 
circumferential  injection,  as  illustrated  in  Fig.  115,  the  lower  portion 
as  described  above.  Another  crescent-like  injection  is  made  from 
above,  which  meets  the  lower  field,  starting  preferably  over  the  exter- 
nal ring  of  the  inguinal  canal  on  each  side,  making  the  injection 
fairly  deep  and  liberal  here  to  thoroughly  block  all  fibers  of  the  ilio- 
inguinal  and  genitocrural  nerves,  as  they  emerge  from  this  opening  to 
be  distributed  to  the  tissues  of  the  labia  majora. 


424 


LOCAL   ANESTHESIA 


Anterior  colporrhaphy  is  done  by  pulling  down  the  cervix  with  a 
volsellum;  at  this  point  on  the  cervix  a  little  infiltration  can  first  be 
done  before  applying  the  instrument.  With  the  cervix  well  down 
and  on  the  stretch  the  submucous  tissues  between  the  cervix  and 
urethral  opening  are  well  infiltrated  (Fig.  116),  carrying  the  infiltra- 
tion well  out  laterally  to  permit  free  exposure  of  the  deep  fascia  in  the 
subsequent  dissections. 


Fig.  116. — Area  of  infiltration  for  anterior  colporrhaphy.     (From  Braun.) 

The  cervix  is  anesthetized  by  drawing  it  down  with  a  volsellum 
and  making  a  free  submucous  infiltration  around  its  neck,  at  its 
junction  with  the  vaginal  vault.  In  making  this  injection  in  front 
care  should  be  exercised  not  to  injure  the  bladder;  the  point  of  the 
descent  of  this  organ  and  its  proximity  to  the  vaginal  vault  had  best 
be  located  beforehand  by  a  sound  passed  within  the  bladder.  A  long 
fine  needle  with  large  syringe  is  now  used,  the  needle  directed  up  in 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS  425 

the  long  axis  of  the  cervix  on  each  side,  just  within  the  cervical  tissues, 
to  a  depth  of  from  i  to  2  inches,  and  about  ^  ounce  of  0.50  per  cent, 
novocain  injected  on  each  side,  injecting  as  the  needle  is  advanced. 

After  a  few  minutes  this  will  permit  a  fair  degree  of  dilatation, 
when  trachelorrhaphy  can  be  done,  combined  with  a  curettage  of  the 
cervical  canal.  Curettage  of  the  body  of  the  uterus  is  not  often  very 
satisfactory  under  local  anesthesia  when  thoroughly  done,  but  a 
limited  amount  is  often  well  tolerated  after  the  above  injections,  or 
a  few  whiffs  of  ether  can  be  given  just  at  this  point  in  the  operation. 

In  cases  requiring  curettage  following  abortion,  the  procedure  is 
usually  very  much  simplified  as  the  cervical  tissues  are  softened  and 
usually  quite  relaxed  and  the  above  method  of  anesthesia  proves 
quite  sufficient.  I  have  occasionally  adopted  the  following  plan  in 
cases  where  the  cervix  was  quite  patulous  or  could  be  first  dilated  by 
the  preliminary  cervical  injections  sufficiently  to  permit  the  intro- 
duction of  a  finger.  With  the  cervix  well  pulled  down  the  index- 
finger  of  one  hand  is  passed  up  in  its  canal  to  the  uterine  cavity. 
The  long  needle  is  then  entered  on  the  vaginal  surface  of  the  cervix 
close  to  the  fornix  and  passed  upward  just  within  the  cervical  wall 
or  in  close  contact  with  it,  under  the  guidance  of  the  finger  within  the 
canal  which  should  at  all  times  be  able  to  feel  the  course  and  position 
of  the  needle,  the  precaution  is  observed  of  freely  injecting  the  solu- 
tion while  the  needle  is  being  advanced.  Deep  injections  made 
high  up  in  the  external  walls  of  the  uterus  in  this  way  on  each  side 
will  reach  any  nerves  from  the  broad  ligaments  and  completely  anes- 
thetize the  uterus  sufficiently  to  permit  a  very  thorough  curettage, 
such  as  may  be  needed  for  the  removal  of  a  submucous  fibroid.  It 
is,  however,  not  always  possible  to  follow  this  plan  as  in  many  of 
these  cases  the  cervix  is  dense  and  unyielding  and  I  have  always 
felt  some  hesitation  in  making  these  deep  injections  in  this  position 
without  some  reliable  guide. 

Ruge  describes  the  method  of  anesthesia  for  a  vaginal  hysterec- 
tomy as  follows: 

"A  long  needle  is  introduced  to  one  side  of  the  cervix  to  a  depth 
of  4  to  5  cm.,  being  directed  in  a  somewhat  lateral  direction,  in  order 
to  strike  the  nerve- trunks  before  they  have  undergone  their  ultimate 
division.  If  the  needle  is  introduced  slowly,  most  vessels  and  any 
coils  of  intestines  with  which  it  may  come  in  contact  will  be  pushed 
aside  and  not  injured.  When  the  needle  has  been  satisfactorily 
introduced,  the  10  c.c.  syringe  is  attached  and  the  solution  injected 
as  the  needle  is  withdrawn. 


426  LOCAL    ANESTHESIA 

"The  process  is  repeated  on  the  opposite  side,  then  at  two  points 
on  the  anterior  and  two  on  the  posterior  vaginal  vault  injections  of 
3  to  5  c.c.  are  made.  In  the  anterior  vaginal  vault  it  is  necessary  to 
introduce  the  needle  2  to  3  cm.  deep,  but  in  the  posterior  just  through 
the  mucosa. 

"Vesical  symptoms  are  controlled  by  using  instillations  to  pre- 
vent pulling  on  the  viscus  from  being  unpleasant." 

This  operation  has  never  been  performed  under  local  anesthesia 
by  the  author,  and  it  would  seem  somewhat  questionable  to  pass  a 
needle  in  any  direction  in  which  it  might  perforate  the  bowel.  If 
the  needle  is  fine  and  the  solution  injected  as  it  is  advanced  the  dan- 
ger of  injuring  the  ureter  or  vessels  at  these  points  is  very  slight,  and 
if  punctured  with  a  fine  needle  no  damage  is  likely  to  result,  but  we 
cannot  feel  the  same  about  the  intestines.  It  would  seem  safer  to 
the  author  in  doing  this  operation  to  first  free  the  bladder  from  the 
uterus  and  open  the  peritoneum  above,  as  was  done  in  the  case  de- 
scribed later,  then  with  a  finger  in  the  cavity  the  broad  ligaments  or 
their  internal  attachments  can  be  infiltrated  under  the  guidance  of 
the  eye  and  finger. 

Thaler,  in  describing  the  technic  for  the  Diihrssen-Bumin  opera- 
tion of  anterior  hysterotomy,  as  done  in  Schauta's  clinic  for  cases 
of  placenta  praevia,  eclampsia,  etc.,  where  rapid  delivery  is  indi- 
cated, states  that  the  injection  is  made  high  up  on  the  anterior  lip 
of  the  cervix  and  to  the  right  and  left  of  the  midline,  well  down  into 
submucous  tissue,  about  i  cm.;  the  cervix  is  slit  up  to  this  point, 
when  further  injections  are  made  into  the  anterior  uterine  wall  as 
the  procedure  progresses.  The  use  of  adrenalin  in  the  solution 
prevents  hemorrhage. 

The  female  bladder  can  be  quite  easily  opened  through  the  vagina 
by  infiltrating  above  and  in  front  of  the  cervix  in  the  middle  line, 
carrying  the  infiltration  well  down  to  the  submucous  tissue  of  the 
bladder.  A  sound  .is  passed  into  the  bladder  and  turned  point  down 
to  present  the  bladder  at  this  point;  unless  the  bladder  is  inflamed  or 
hypersensitive  it  is  not  necessary  to  anesthetize  it;  when  necessary 
it  is  done  in  the  same  way  recommended  for  the  male  bladder.  The 
infiltration  of  the  submucous  tissues  over  the  point  of  incision  is 
sufficient  to  anesthetize  the  mucosa  here,  and  its  incision  causes  no 
discomfort. 

Operations  for  vesicovaginal  fistula,  if  easily  accessible,  can  be 
performed  in  this  same  way  by  infiltrating  around  the  opening,  the 


GENITO-URINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   427 

infiltration  facilitating  the  separation  of  the  bladder  from  the  vaginal 
wall. 

The  female  urethra  is  easily  anesthetized  by  a  film  of  cotton 
placed  around  the  end  of  a  probe,  and  saturated  with  a  5  or  10  per 
cent,  solution  of  novocain  passed  into  the  urethra  and  allowed  to 
remain  for  a  few  minutes. 

Caruncles  are  easily  extirpated  by  infiltrating  around  and  beneath 
them;  a  swab  with  10  per  cent,  solution  can  be  used  on  the  surface 
for  a  few  minutes  at  the  point  at  which  the  needle  is  entered. 

The  removal  of  Bartholin's  glands  or  benign  growths  is  quite 
easily  performed  by  infiltration;  also  epitheliomata  when  superficial 
and  of  limited  extent;  malignant  diseases  of  the  cervix,  uterus,  or 
deeper  parts  should  not  be  undertaken  by  these  measures,  but 
reserved,  for  parasacral,  epidural,  spinal,  or  general  anesthesia. 

In  operating  upon  the  cervix  and  uterus,  pulling  down  these  parts 
to  the  vaginal  outlet  is  attended  with  some  discomfort,  and  should 
not  be  attempted  where  they  are  bound  down  by  adhesions  or  fixed 
in  the  abdominal  cavity,  but  in  cases  where  these  parts  are  well 
relaxed  and  freely  movable  operation  can  be  quite  satisfactorily 
undertaken. 

Polypi  can  also  be  removed  in  this  way,  or  even  without  anes- 
thesia, as  they  have  no  sensation  and  the  division  of  their  pedicle 
is  without  pain.  Where  the  parts  can  be  well  brought  down,  as  in 
prolapse,  the  peritoneal  cavity  can  be  easily  opened  in  front  of  the 
uterus,  its  fundus  brought  down,  and  any  of  the  various  fixation 
operations  performed. 

The  following  history  illustrates  an  extensive  operation  upon 
these  parts  on  a  favorable  subject: 

Mrs.  H.,  aged  sixty-three,  a  stout  lady  with  flabby  and  relaxed  tissues,  had  been  suf- 
fering with  a  complete  prolapse  of  the  uterus  with  marked  rectocele  and  cystocele  for  the 
past  fifteen  years,  the  result  of  extensive  lacerations  during  the  child-bearing  period. 
The  bladder  and  rectum  hung  down  from  the  vagina  like  two  distended  pouches,  the 
uterus  protruding  from  between  them,  making  it  necessary  for  her  to  replace  it  before  she 
could  sit  down.  She  suffered  the  usual  disturbances  with  the  bladder  and  rectum  as  well 
as  the  other  symptoms  common  to  this  condition;  her  dread  of  an  anesthetic  had  forced 
her  to  tolerate  these  discomforts  for  many  years.  When  I  assured  her,  much  to  her 
surprise,  that  she  could  be  easily  and  painlessly  operated  on  under  local  anesthesia  she 
embraced  the  opportunity  readily. 

The  Operation. — The  anterior  vaginal  wall  in  the  midline,  between  the  cervix  and 
meatus,  was  first  infiltrated  and  then  incised  down  to  the  bladder  wall;  the  infiltration 
and  dissection  was  carried  well  out  to  the  sides  to  freely  separate  the  bladder  from  the 
surrounding  parts;  the  same  was  done  with  its  attachment  to  the  uterus.  The  perito- 
neal cavity  between  the  bladder  and  uterus  was  then  opened,  and,  with  one  finger  holding 
up  the  bladder,  a  long  needle  was  used  to  inject  a  small  area  on  the  anterior  surface  of 


428  LOCAL   ANESTHESIA 

the  uterus  to  prevent  any  pain  which  might  be  caused  by  catching  the  organ  at  this  point 
with  tenaculum  forceps;  the  uterus  was  then  secured  and  anteverted,  so  as  to  bring  its 
fundus  forward  into  the  wound  in  the  vagina;  it  was  held  here  while  the  bladder  was 
pushed  up  well  into  the  cavity  and  behind  it,  and  the  fundus  secured  to  the  deep  fascia 
behind  the  pubis;  thus  firmly  anchored  in  this  position  it  prevented  the  descent  of  the 
bladder  and  was  itself  prevented  from  retroverting,  the  first  step  necessary  for  its 
descent;  the  superficial  parts  were  then  closed.  The  perineum  was  now  dealt  with  by 
commencing  at  the  vaginal  outlet  and  making  a  rather  free  submucous  infiltration, 
extending  well  back  in  the  middle  line  and  well  out  on  each  side.  The  mucous  mem- 
brane was  then  incised  from  side  to  side  at  the  vaginal  outlet  and  dissected  up  freely, 
this  step  being  markedly  facilitated  by  the  infiltration  which  separated  the  rectum  from 
the  vaginal  mucosa  and  greatly  lessened  the  danger  of  opening  the  rectum  so  likely  to 
happen  in  bad  cases  of  this  kind.  The  muscles  in  the  vaginal  walls  were  next  sought  for, 
and  their  atropic  remnants  approximated  in  the  middle  line,  restoring  a  fairly  satisfac- 
tory perineum  and  normal  vaginal  outlet.  After  trimming  away  the  excess  of  vaginal 
mucosa  the  wound  was  closed.  This  entire  procedure  was  without  pain  and  the  con- 
valescence without  incident. 

It  is  now  six  years  since  the  operation  was  performed.  During 
this  interval  I  have  heard  from  the  patient  repeatedly,  and  she  has 
remained  entirely  well.  The  infiltration  method  was  used  for  the 
above  case  instead  of  the  regional  injection  of  the  pudic  nerves,  as 
the  infiltration  greatly  facilitates  the  separation  of  the  different 
planes  of  tissues  in  cases  of  this  kind,  and  the  work  is  more  quickly 
and  easily  done  that  under  a  general  anesthesia  without  the  aid  of 
infiltration. 

Operations  upon  the  round  ligaments  in  the  inguinal  canal  for 
purposes  of  shortening  them  by  the  Alexander  method  or  any  of  its 
modifications  is  quite  easily  done  under  infiltration,  and  should  be 
governed  by  the  same  indications  as  when,  operating  under  general 
anesthesia,  that  is,  the  free  movability  of  the  uterus  and  other  internal 
parts. 

Infiltration  is  first  done  over  the  external  ring  and  along  the 
course  of  the  inguinal  canal;  the  superficial  parts  are  incised,  and 
the  external  ring  and  aponeurosis  of  the  external  oblique  exposed; 
an  injection  is  then  made  through"  the  fibers  of  the  external  oblique 
into  the  inguinal  canal,  the  canal  then  opened,  and  round  ligaments 
located  and  freed.  As  it  is  being  drawn  through  the  internal  ring, 
the  tissues  around  this  point  down  to  the  peritoneum  are  infiltrated 
with  a  fine  needle,  bearing  in  mind  the  position  of  the  deep  epigastric 
artery.  By  proceeding  in  this  way  the  drawing  of  the  ligament 
through  the  internal  ring  and  stripping  back  of  the  peritoneum  causes 
no  pain. 

Suprapubic  cystotomy  is  performed  the  same  in  the  female  as  in 
the  male,  but  it  is  easier  to  perform  cystotomy  by  the  vaginal  route, 


GENITOURINARY,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS   429 

as  has  already  been  described,  and  if  to  be  left  open  for  drainage  it 
is  more  convenient,  as  the  patient  can  wear  a  urinal  and  not  be 
continually  soiled  as  with  a  suprapubic  opening. 

In  operating  within  the  abdominal  cavity  only  a  limited  number 
of  operations  are  feasible,  and  only  then  under  favorable  conditions, 
with  free  movability  of  the  parts.  In  the  presence  of  adhesions  or 
inflammation  about  the  tubes  or  ovaries  the  case  should  be  operated 
by  other  methods.  The  abdomen  is  opened  in  the  middle  line  after 
infiltration,  first  of  the  skin  and  subcutaneous  tissues,  then  passing 
the  needle  down  to  the  interval  between  the  recti  muscles;  after 
these  have  been  opened  the  subperitoneal  tissue,  which  is  quite 


L  ine  of  ane.sf/>e-si'a. 


Wall    C.uJ" 

Fig.  117. — Shows  uterus,  broad  ligament,  and  attachments.  Series  of  circles  shows 
line  of  infiltration  beneath  anterior  peritoneal  fold  of  broad  ligament.  Where  this  line 
crosses  uterus,  in  shaded  portion,  infiltration  is  more  liberal.  On  left  is  seen  small  line 
joining  longer  one  at  about  right  angles,  and  shows  area  infiltrated  when  limited  to  one 
side  as  in  the  case  of  removal  of  tube  and  ovary  only.  Similar  infiltrations  are  made 
posteriorly,  as  described  in  text. 

relaxed  at  this  point,  is  now  infiltrated,  this  infiltration  anesthetizing 
the  peritoneum.  (See  chapter  on  Abdominal  Operations.)  After  a 
few  minutes  this  is  opened.  Retractors  should  be  gently  used,  as 
any  undue  traction  on  the  abdominal  wall  will  cause  pain.  The 
uterus  should  be  raised  into  the  wound  with  the  hand,  not  with 
volsellum  or  other  toothed  instruments,  unless  the  point  at  which 
they  are  applied  has  first  been  infiltrated.  A  variety  of  operations 
are  now  possible — salpingo-oophorectomy,  when  these  parts  are 
free,  by  lightly  infiltrating  the  broad  ligaments,  pelvic  and  uterine 
attachments,  of  these  parts  along  the  proposed  line  of  incision  on  their 
anterior  and  posterior  surfaces  (Fig.  117);  pedunculated  ovarian 
cysts,  when  not  adherent,  are  quite  easily  removed  in  the  same 


430  LOCAL   ANESTHESIA 

way;  subperitoneal  fibroids  removed,  or  resection  of  the  body  of  the 
uterus  performed  by  first  lightly  infiltrating  the  proposed  line  of 
incision;  this  can  often  be  omitted,  as  the  uterus  has  very  little  sensa- 
tion; ventrosuspension,  or  fixation,  is  quite  easily  done,  and  usually 
without  any  discomfort;  if  any  is  experienced,  light  infiltration  can 
be  resorted  to  on  the  fundus,  where  the  sutures  are  to  be  placed. 

Intra-abdominal  operations  for  purposes  of  shortening  the  round 
ligaments  may  be  done  under  local  anesthesia,  but  it  would  be  prefer- 
able to  do  an  external  Alexander,  unless  the  cavity  has  already  been 
opened.  The  ligaments  may  be  doubled  on  themselves  and  sutured, 
using  light  infiltration  at  these  points  if  necessary  or  fixed  behind  the 
uterus.  The  various  operations  of  drawing  the  ligaments  through 
the  abdominal  wall,  at  or  near  the  internal  ring,  may  also  be  done 
by  first  raising  the  abdominal  wall  gently  and  infiltrating  the  perito- 
neum and  subperitoneal  tissue  around  these  points,  as  well  as  the 
tract  through  which  the  forceps  will  be  passed  through  the  abdominal 
wall  in  grasping  the  ligaments,  remembering  the  location  in  this 
neighborhood  of  the  deep  epigastric  artery  and  vein  and  making  the 
injection  only  when  advancing  or  withdrawing  the  needle. 

Cesarean  section  can  be  quite  easily  performed  under  local 
methods  when  other  forms  of  anesthesia  are  contra-indicated. 

In  thes'e  cases  the  abdominal  wall  is  much  thinned  out  and  no 
muscles  in  evidence  in  the  midline.  The  proposed  point  of  incision 
is  located  and  the  skin  and  subcutaneous  tissue  infiltrated  for  a  dis- 
tance of  6  or  8  inches;  these  are  incised  down  to  the  aponeurosis;  the 
needle  now  penetrates  this  at  several  points  and  freely  infiltrates  the 
subperitoneal  tissue  beneath  for  the  entire  length  of  the  field. 

The  aponeurosis  and  peritoneum  are  then  incised  bringing  into 
view  the  uterus.  The  wound  is  now  retracted  and  subperitoneal 
injections  made  in  all  directions  to  enlarge  the  field  of  anesthesia. 
The  uterus  is  ordinarily  not  sensitive  but  may  be  infiltrated  lightly 
along  the  proposed  line  of  incision.  Before  opening  the  uterus  it  is 
best  to  have  it  well  secured  at  several  points  as  well  as  the  wound 
in  the  abdominal  wall  to  follow  down  the  uterus  as  it  contracts  and 
prevent  the  possible  escape  of  intestines  which  is  unlikely  but  may 
occur  if  the  patient  bear  down.  The  steps  of  the  operation  are  other- 
wise no  different  than  when  using  a  general  anesthetic.  The  possi- 
ble psychical  effects  upon  the  patient  should  not  be  overlooked  and 
she  should  receive  an  hour  beforehand  the  preliminary  hypodermic 
of  pantopon  or  morphia  and  scopolamin. 

The  following  is  from  a  paper  by  Drs.  R.  K.  Smith  and  Jacob 


GENITO-URINARy,  ANORECTAL,  AND  GYNECOLOGIC  OPERATIONS       431 

Schwarz,  of  San  Francisco,  read  at  the  San  Francisco  Medical  Society, 
May,  1910.  In  both  cases  there  was  a  contracted  pelvis  with  contra- 
indications to  general  anesthesia;  in  both  cases  mother  and  child 
survived : 

"The  solution  used  was  novocain  (0.50  per  cent.),  to  each  10  c.c. 
of  which  was  added  i  drop  of  adrenalin  solution  (1:1000).  This 
solution  was  freshly  made  and  boiled  for  five  minutes  before  using. 
Two  points,  one  9  cm.  above  the  umbilicus  and  the  other  a  like  dis- 
tance below  it  in  the  median  line,  were  infiltrated  with  a  drop  of  the 
solution,  and  from  these,  as  points  of  departure,  the  solution  was 
injected  about  a  diamond-shaped  area  subcutaneously  and  then  sub- 
fascially.  The  line  of  the  incision  was  not  infiltrated  in  either  of  these 
cases.  The  amount  of  solution  used  was  about  75  c.c.  in  Case  i  and 
60  c.c.  in  Case  2,  and  it  is  my  belief  that  a  smaller  amount  might  be 
sufficient. 

"The  operation  was  carried  out  as  follows:  Incision  through  the 
abdominal  wall,  15  cm.  long,  with  its  center  opposite  the  umbilicus, 
peritoneal  cavity  packed  off  with  gauze,  uterus  incised  with  knife 
down  to  the  placenta  for  about  i  inch,  and  the  incision  rapidly  en- 
larged with  scissors  to  about  15  cm.;  the  placenta  pushed  aside,  the 
membranes  ruptured,  the  child  grasped  by  its  feet  and  extracted,  and 
the  placenta  removed  from  the  uterus  while  it  was  in  situ;  the  uterus 
lifted  out  of  the  abdominal  cavity  and  surrounded  by  pads  dipped 
in  hot  saline  solution.  In  Case  i  the  hand  was  introduced  through 
the  incision  into  the  cavity  of  the  uterus  and  one  finger  passed 
through  the  cervix,  this  was  followed  by  a  Goodell  dilator,  which  was 
carried  through  the  cervix  and  stretched  open.  This  was  not  neces- 
sary in  Case  2,  operated  upon  on  April  4,  1910,  as  the  cervix  was  com- 
pletely dilated  before  beginning  the  operation.  The  uterine  incision 
was  closed  with  deep  and  superficial  interrupted  sutures  of  chromic 
catgut,  and  there  buried  with  a  continuous  Lembert  suture  of  the 
peritoneum,  the  peritoneal  cavity  wiped  out,  and  the  wound  closed." 


CHAPTER  XX 
SPINAL  ANALGESIA 

SPINAL  analgesia1  had  its  beginning  in  the  experiments  of  Dr.  J. 
Leonard  Corning,  which  were  published  in  the  "New  York  Medical 
Journal,"  October  31,  1885. 

Corning  first  experimented  on  a  dog,  injecting  a  2  per  cent,  cocain 
solution  in  the  lower  dorsal  region,  and  obtained  paralysis  of  motion 
and  sensation  in  about  five  minutes,  followed  by  complete  recovery, 
without  noticeable  ill  effects.  He  next  injected  a  man  suffering  from 
sexual  disturbances,  using  30  minims  of  a  3  per  cent,  cocain  solution, 
between  the  eleventh  and  twelfth  dorsal  vertebrae.  There  was  no 
result  in  eight  minutes,  and  the  injection  was  repeated,  producing 
anesthesia  and  incoordination  of  the  lower  extremities.  The  anes- 
thesia was  complete,  as  proved  by  various  tests;  urethral  sounds  were 
passed  and  other  manipulations  used  about  the  genitalia.  This  was 
done  in  the  office.  In  an  hour  the  patient  was  able  to  leave  with 
sensation  still  impaired,  but  otherwise  no  worse  for  his  experience. 

Corning,  in  concluding,  states: 

"Whether  the  method  will  ever  find  an  application  as  a  substitute 
for  etherization  in  genito-urinary  or  other  branches  of  surgery  further 
experiences  alone  can  show.  Be  the  destiny  of  the  observation  what 
it  may,  it  has  seemed  to  me,  on  the  whole,  worth  recording." 

Corning  was  not  a  surgeon,  and  did  not  have  the  opportunities 
of  applying  this  method  further,  and,  as  it  did  not  attract  favorable 

1  To  Prof.  R.  Matas  is  probably  due  the  credit  of  having  performed  the  first  opera- 
tion under  spinal  analgesia  in  America.  An  operation  for  hemorrhoids  was  performed 
upon  a  young  colored  male  in  the  Charity  Hospital  Clinic  on  December  18,  1899,  Profs. 
F.  A.  Larue  and  H.  B.  Gessner  assisting,  with  the  author,  then  an  intern  in  his  service. 
The  spinal  canal  was  reached  between  the  fourth  and  fifth  lumbar  vertebras,  with  escape 
of  spinal  fluid;  two  injections  were  made  five  minutes  apart,  each  about  i  c.c.  of  i  per 
cent,  cocain  in  normal  salt  solution;  anesthesia  immediately  followed,  and  was  complete 
from  the  waist-line  down,  with  a  gradually  lessening  degree  of  anesthesia  reaching  as  far 
up  as  the  neck.  Some  reaction  followed  the  operation  (chill,  nausea,  vomiting,  and 
temperature),  which  shortly  subsided,  the  patient  making  a  good  recovery. 

An  unsuccessful  attempt  had  previously  been  made  on  November  loth  with  beta- 
eucain,  but  the  resulting  anesthesia  was  unsatisfactory.  (Jour.  Amer.  Med.  Assoc., 
December  30,  1899,  p.  1659.) 

432 


SPINAL   ANALGESIA  433 

attention  at  the  time  on  the  part  of  his  American  confreres,  it  was 
accordingly  dropped  until  revived  some  years  later  by  Continental 
surgeons. 

In  these  experiments  Corning  had  aimed  to  inject  the  fluid  be- 
tween the  spinous  processes,  and  permit  it  to  be  carried  by  the  veins 
to  the  cord.  Corning  deals  with  the  subject  again  in  1888,  and  in 
1894  appeared  his  book  on  "Pain  in  its  Neuropathological,  Diagnos- 
tic, Medicolegal,  and  Neurotherapeutic  Relations." 

Coming's  intention  was  to  make  the  injection  into  the  neighbor- 
hood of  the  cord;  he  did  not  aim  to  puncture  the  membranes; 
whether  this  occurred  or  not,  he  must  at  least  have  gotten  within  the 
canal,  else  it  is  hard  to  understand  how  anesthesia  resulted,  as  it 
could  not  take  place  from  diffusion,  as  the  cord  is  well  isolated  from 
its  perivertebral  surroundings,  and  it  is  not  at  all  likely  that  it  could 
be  carried  to  the  cord  by  the  surrounding  circulation  in  any  effective 
quantity.  This,  then,  was  the  first  attempt  at  a  paravertebral  in- 
jection, but  was,  no  doubt,  intraspinal  if  not  intrameningeal. 

Real  interest  in  the  method  was  aroused  in  1891  by  the  lumbar 
puncture  of  Quincke,  which  was  developed  largely  by  the  activity  of 
Continental  surgeons,  notably  by  Bier  and  Tuffier. 

Bier,  with  admirable  courage,  first  tried  the  method  upon  himself, 
to  more  accurately  observe  its  effects.  The  anesthesia  was  satis- 
factory. It  was  followed  by  a  slight  headache. 

The  method  was  soon  in  general  use  on  the  Continent  and  in 
America,  but  did  not  so  early  gain  followers  in  England,  probably  due 
to  conservatism,  as  well  as  to  the  fact  that  here  general  anesthesia 
had  reached  a  high  plane  of  development,  being  regarded  as  a  spe- 
cialty and  given  largely  by  professional  anesthetists. 

The  wave  of  enthusiasm  which  followed  the  general  introduction 
of  this  method  like  all  other  radical  innovations  was  followed  by  a 
reaction.  As  statistics  accumulated  it  was  found  that  the  method 
could  not  compare  in  safety  with  ether  anesthesia.  Following  this 
reaction  the  method  was  dropped  as  a  routine  procedure  from  most 
large  clinics  but  was  persisted  in  by  a  few  who  assiduously  sought  to 
improve  the  results  obtained,  by  the  general  handling  of  the  patient, 
the  preparation  of  the  solution  used  and  the  technic  of  its  adminis- 
tration. While  much  has  been  accomplished  in  this  direction  and 
the  results  somewhat  improved,  it  is  yet  not  a  method  for  routine  use, 
but  has,  however,  a  decided  field  of  usefulness  in  selected  cases  and 
under  certain  conditions. 

Within  the  last  five  years  some  improvement  has  occurred  in  the 


434  LOCAL   ANESTHESIA 

results  obtained  from  spinal  anesthesia  and  a  vast  addition  made  to 
the  clincical  experience  on  the  subject,  but  remarkably  little  on 
the  experimental  or  physiological  aspects  of  the  subject.  The  im- 
mediate danger  following  spinal  analgesia  may  occur  as  a  result  of 
paralysis  of  the  respiratory,  bulbar  vaso-motor  and  other  higher  cen- 
ters, but  what  is  more  common  is  a  paralysis  of  the  efferent  nerve- 
fibers  which  control  the  blood-pressure  in  the  splanchnic  area  and 
may  lead  to  an  immediate  and  profound  fall  in  the  blood-pressure  in 
these  areas  and  the  patient  literally  bled  to  death  by  dilatation  of  the 
great  venous  trunks.  Smith  and  Porter  show  that  rabbits  can  be 
bled  to  death  within  their  portal  system  by  a  section  of  the  splanchnic 
nerves.  A  sudden  and  profound  fall  in  the  general  blood-pressure 
produced  by  this  result  may  so  exsanguinate  the  "master  cells"  in 
the  medulla  and  leave  them  insufficiently  supplied  with  oxygen  as 
to  produce  the  most  serious  consequence.  The  higher  the  puncture 
is  made  the  greater  the  danger  of  these  results.  For  this  reason  the 
high  dorsal  and  cervical  punctures,  which  at  one  time  were  tried, 
should  now  be  permanently  abandoned  in  the  present  stage  of  de- 
velopment of  this  method  and  these  injections  should  be  confined  to 
the  lumbar  region. 

In  considering  the  limited  laboratory  findings  available,  it  is 
probable  that  many  deaths  reported  as  due  to  paralysis  of  the  res- 
piratory centers  from  the  drug  having  reached  this  level,  were  in 
reality  due  to  splanchnic  paralysis  and  vaso-motor  collapse  lowering 
the  blood-pressure  within  these  points  to  a  point  incompatible  with 
life. 

It  would  certainly  be  ideal  if  a  drug  were  found  capable  of  para- 
lyzing alone  the  afferent  sensory  paths  in  the  cord,  but  drugs  cannot 
differentiate  between  nerve-tissue,  and  the  efferent  vasomotor 
fibers  must  inevitably  feel  this  influence. 

According  to  the  results  of  Smith  and  Porter,  the  bulk  of  the 
solution  seemed  to  be  of  greater  importance  than  its  strength — 
diluted  solutions  as  a  rule  spread  further  than  concentrated  ones. 

The  work  of  Smith  and  Porter  has  proved  extremely  valuable  and 
shows  that  in  the  safe  use  of  spinal  anesthesia,  we  must  seek  only  to 
paralyze  the  afferent  sensory  paths,  without  a  too  pronounced  effect 
upon  the  efferent  vasomotors,  and  that  any  rational  surgical  prog- 
ress with  this  method  must  be  in  this  direction. 

A  thorough  understanding  of  spinal  anesthesia  is  not  possible 
without  the  consideration  of  certain  anatomic,  mechanical,  and 
physiologic  facts. 


SPINAL   ANALGESIA 
ANATOMY 


435 


The  spinal  cord  ends  opposite  the  Jower  border  of  the  first  lumbar 
vertebra  (in  the  child,  and  occasionally  in  women,  opposite  the  third 
lumbar),  in  the  filum  terminalis,  which  is  given  off  from  the  conus 
terminalis  (Fig.  118). 


coccygeat  nerve 


Fig.  118. — An  anterior  view  of  the  lower  portion  of  the  spinal  cord.     The  dura  mater  has 
been  divided  longitudinally.     (Sobotta  and  McMurrich.) 

The  spinal  cord  and  cauda  equina  are  surrounded  by  the  same 
membranes  as  the  brain — viz.,  dura,  arachnoid,  and  pia. 

The  dura,  continuous  with  that  which  invests  the  brain,  is  a  loose 
sheath,  not  attached  to  the  .bony  framework  of  the  spinal  canal,  but 
separated  from  it  by  loose  areolar  tissue  containing  a  plexus  of  veins 
which  are  most  numerous  in  front  and  on  the  sides,  less  so  posteriorly. 


436  LOCAL   ANESTHESIA 

The  dural  sac  terminates  at  the  third  sacral  segment.  It  is  attached 
by  fibrous  slips  to  the  posterior  common  ligament,  and  is  largest  in 
the  cervical  and  lumbar  regions.  At  the  beginning  of  the  cauda 
equina  the  nerves  lie  in  bundles  on  each  side,  with  an  appreciable 
interval  between,  through  which  runs  the  filum  terminale.  They 
approach  each  other  lower  in  the  lumbar  region  and  surround  the 
filum,  which  continues  to  the  termination  of  the  dural  sac  and  blends 
with  its  attachment  to  the  periosteum  of  the  coccyx. 

On  the  side  of  the  cord  and  in  the  cauda  equina  the  motor  nerves 
lie  in  front,  the  sensory  behind;  on  the  side  of  the  cord,  separated 
by  the  ligamentum  denticulatum;  in  the  cauda  equina,  still  separated 
by  an  irregular  cribriform  membrane.  This  accounts  for  the  motor 
nerves  not  being  more  regularly  reached  and  affected  by  the  anes- 
thetic fluid  in  spinal  puncture. 

The  arachnoid  is  separated  from  the  dura  by  a  slight  interval, 
the  subdural  space. 

Within  the  arachnoid  membrane,  the  subarachnoid  space,  is  the 
cerebrospinal  fluid.  This  space  is  of  considerable  size  and  is  largest 
at  the  lower  part  of  the  spinal  canal.  Within  this  space  is  the  cauda 
equina.  This  space  communicates  above,  through  the  foramen  of 
Magendie,  with  the  subarachnoid  and  general  ventricular  cavity  of 
the  brain.  The  space  is  partially  divided  by  a  longitudinal  cribri- 
form membrane,  connecting  the  dura  with  the  pia  membrane. 

It  will  be  seen  from  the  above  description,  as  well  as  by  consulting 
Fig.  1 1 8,  that  the  most  favorable  site  for  the  spinal  puncture  is  the 
midlumbar  region,  for  here  the  cauda  equina  lies  in  two  bundles  on 
each  side  of  the  middle  line,  and  is  less  likely  to  be  injured  by  a 
needle  introduced  at  this  point,  which  has  been  termed  the  "cisterna 
terminalis"  by  Donitz. 

ANESTHETIC  AGENTS 

Nearly  all  agents  that  have  been  used  for  local  anesthesia  have 
at  some  time  or  other  been  used  for  spinal  analgesia.  That  none  of 
these  have  proved  thoroughly  satisfactory  accounts  for  the  change 
from  one  to  the  other. 

The  advent  of  spinal  anesthesia  was  before  the  introduction  of 
some  of  the  more  recently  discovered  anesthetics. 

Cocain  was  the  first  used,  and  was  soon  found  to  be  too  dangerous 
to  justify  its  continuance  by  the  majority  of  operators,  but  is  still 
used  by  some  few;  6  to  10  minims  of  a  2  to  4  per  cent,  solution  is  the 
strength  usually  employed. 


SPINAL  ANALGESIA  437 

Beta-eucain  was  employed,  but  was  found  unsatisfactory. 

Stovain  next  claimed  attention.  It  was  introduced  by  Fourneau 
in  1904,  and  was  first  used  by  Chaput  and  Turner,  and  for  a  time  be- 
came the  agent  most  in  use.  It  possessed  some  noteworthy  proper- 
ties. Its  solutions  were  able  to  stand  boiling  without  decomposition, 
and  it  possessed  mild  antiseptic  properties.  It  is  freely  soluble  in 
water  and  is  of  a  feeble  acid  reaction.  It  has  a  more  marked  effect 
upon  motor  nerves  than  has  cocain,  paralyzing  all  the  sphincters- 
anal,  uterine  and  vesical — as  well  as  producing  general  muscular 
relaxation  when  it  comes  in  contact  with  the  motor  roots.  This  is  of 
decided  advantage  in  operating  upon  the  abdomen  and  perineum ;  in 
laparotomy  it  permits  wide  retraction  of  the  abdominal  muscles, 
which  greatly  facilitates  the  work.  This  paralyzing  action  on  the 
motor  nerves  may  reach  high  enough  to  effect  the  respiratory  nerves 
or  even  the  centers  in  the  medulla,  and  thus  add  a  grave  danger  to  its 
action.  It  is  somewhat  irritating  to  the  tissues  as  well  as  to  the  nerve- 
fibers. 

Alypin  has  been  used,  but  has  been  discarded  as  being  unsuited 
for  use  in  the  spinal  canal. 

Novocain,  the  least  toxic  (one-sixth  as  toxic  as  cocain)  and  least 
irritating  of  all  the  local  anesthetics,  has  been  applied  to  spinal  anes- 
thesia, but  has  not  proved  generally  satisfactory,  and  is,  accordingly, 
less  used  at  the  present  time.  Its  action  on  motor  nerves  is  much 
less  marked  than  that  of  stovain,  and  there  is,  accordingly,  less  dan- 
ger of  respiratory  paralysis.  The  usual  dose  is  about  i  gr. 

Tropococain  is  the  agent  most  popular  at  the  present  time,  and 
is  being  generally  adopted  by  most  operators.  Less  unfavorable  re- 
sults have  been  reported  from  its  use.  From  %  to  i  gr.  is  the  dose 
usually  employed.  The  smaller  dose,  for  peripheral  operations,  the 
larger  dose  for  abdominal  operations  and  those  upon  the  trunk. 

The  method  of  preparing  the  various  agents  differs  largely  in  the 
hands  of  different  operators. 

Most  operators  prefer  to  use  5  or  10  per  cent,  strengths  in  sterile 
solutions  of  the  various  agents,  using  a  sufficient  number  of  minims 
to  give  the  desired  strength  of  the  drug.  The  solution  used  may 
contain  a  definite  quantity  of  sodium  chlorid  to  make  it  isotonic  with 
the  cerebrospinal  fluid.  This  may  be  injected  directly  into  the 
spinal  cord,  or,  as  practised  by  Bier,  and  Tuffier,  at  present,  the  re- 
quired quantity  of  the  solution  is  placed  in  the  syringe  and  an  equal 
quantity  of  cerebrospinal  fluid  drawn  into  the  syringe  before  in- 
jecting into  the  canal.  Similarly,  the  dry  sterile  salt  may  be  placed 


438  LOCAL  ANESTHESIA 

in  the  barrel  of  the  syringe  and  dissolved  in  the  aspirated  fluid  before 
injection.  This  last  method  is  becoming  more  popular. 

Tablets  of  the  various  drugs  used  in  the  usual  strength  employed, 
with  or  without  adrenalin,  but  usually  containing  a  small  amount  of 
sodium  chlorid,  are  placed  on  the  market  by  various  manufacturers. 

The  tablets  are  sterilized  and  in  sterile  containers,  and  when 
mixed  with  a  definite  quantity  of  sterile  water  produce  a  solution 
isotonic  with  the  cerebrospinal  fluid. 

The  keeping  qualities  of  the  tablets  for  any  length  of  time  is  some- 
what in  question,  particularly  if  they  contain  adrenalin  preparations; 
also  the  power  of  rendering  and  keeping  them  sterile. 

Sterile  ampules,  similar  to  those  used  for  serums,  each  containing 
the  recognized  dose  of  the  agent  in  use,  are  put  up  by  the  various  manu- 
facturers in  this  country  and  abroad.  It  is  a  convenient  and  safe 
method,  provided  the  contents  of  the  ampule  can  be  thoroughly 
depended  upon.  When  about  to  be  used  they  are  first  immersed  in  a 
strong  antiseptic  solution — bichlorid,  carbolic  acid,  or  alcohol — 
before  being  opened  by  the  operator,  who  opens  them  just  before  he 
is  ready  to  withdraw  their  contents. 

Adrenalin. — Whether  or  not  adrenalin  should  be  used  in  the 
spinal  canal  is  a  question  much  in  doubt.  At  one  time  it  was  most 
favorably  thought  of  by  most  of  the  leading  operators — Bier,  Tuffier, 
Braun,  and  Donitz — but  later  there  has  been  a  reaction  against  its 
use.  Braun  has  explained  its  favorable  action  by  stating  that  it 
contracts  the  vessels  in  and  around  the  cord,  thus  creating  a  larger 
space  in  the  dural  sac  and  producing  a  flow  of  cerebrospinal  fluid  in 
this  direction,  thus  lessening  the  tendency  of  the  anesthetic  solution 
to  ascend  and  produce  disturbing  symptoms.  These  views,  how- 
ever, have  radically  changed.  .  That  adrenalin  does  prolong  and  in- 
tensify the  action  of  some  anesthetics,  but  limits  the  extent  of  their 
action,  when  injected  with  them  into  the  spinal  canal  is  confirmed 
by  some  observers,  but  its  use  did  not  seem  to  prevent  the  drop  in 
blood-pressure.  With  some  anesthetics,  notably  tropacocain,  it  is 
contra-indicated,  as  the  anesthetic  agent  opposes  the  action  of  adrena- 
lin. We  cannot  draw  a  conclusion  here  by  a  comparison  of  the  action 
of  adrenalin  when  used  in  the  tissues  with  a  local  anesthetic,  where  it 
is  of  decided  value. 

In  the  spinal  canal  we  are  dealing  with  an  open  lymph-sac.  The 
adrenalin  here  must  expend  its  influence  upon  the  vessels  of  the  cauda, 
and  cannot  aid  directly  in  retaining  the  anesthetic  in  situ. 

The  congestion  and  ecchymosis  sometimes  seen  to  follow  its  ac- 


SPINAL   ANALGESIA  439 

tion  in  the  tissues  may  here,  in  the  loosely  supported  vessels  of  the 
cord  and  meninges,  have  a  more  pronounced  effect,  which  may  lead 
to  unpleasant  sequelae. 

ISOTONIC  QUALITIES  AND  SPECIFIC  GRAVITY  OF  ANESTHETIC 
SOLUTIONS  AND  THEIR  MOVEMENTS  WITHIN  THE  CANAL 

It  is  generally  believed  that  the  cerebrospinal  fluid  moves  freely 
in  and  out  of  the  spinal  canal  with  changes  in  the  position  of  the  body, 
that  is,  from  the  erect  to  the  recumbent  or  inverted  positions.  The 
tension  within  the  membranes  must  certainly  be  influenced  by  such 
changes,  but  I  doubt  that  there  is  as  free  movement  to  and  from  the 
cranial  cavity  as  we  have  been  led  to  believe,  for  the  following  reasons : 

The  spinal  canal  is  surrounded  by  an  unyielding  bony  framework, 
and  is  uninfluenced  by  pressure  upon  it  from  the  outside.  The  space 
within  the  canal  must  always  be  rilled,  a  vacuum  cannot  exist.  If 
the  body  is  inverted  and  the  fluid  runs  into  the  cranial  cavity,  what 
is  to  take  its  place?  The  position  is  certainly  not  favorable  for  an 
engorgement  of  the  venous  plexuses  around  the  canal;  besides,  the 
inverted  position  readily  congests  the  large  venous  cavities  within 
the  skull,  and  must  increase  the  pressure  here,  making  less  room  for 
the  entrance  of  the  spinal  fluid.  That  such  change  of  position  does 
influence  the  pressure  within  the  canal  we  must  readily  admit,  but 
that  there  is  any  extensive  to-and-fro  movement  is  no  doubt  an  error, 
but  probably  takes  place  to  only  a  limited  extent. 

Investigations  made  upon  the  open  canal  of  animals  is  of  no  value, 
for  here  the  atmospheric  pressure  which  enters  through  the  opening 
permits  the  fluid  to  be  displaced.  The  results  of  experiments  upon 
animals  cannot  be  applied  to  man.  The  dog  has  only  about  6  c.c.  of 
cerebrospinal  fluid  throughout  the  entire  subarachnoid  space,  while 
in  the  monkey  it  is  still  less,  and  the  cord  and  meninges  fill  the  canal 
closely. 

It  is  absolutely  necessary  that  the  injected  fluid  be  as  nearly  iso- 
tonic  with  the  cerebrospinal  fluid  and  as  free  from  irritating  qualities 
as  possible.  This,  as  determined  by  the  usual  physical  tests  to 
which  the  liquid  is  subjected,  is  not  reliable,  as  proved  by  the  investi- 
gations of  Dr.  A.  E.  Barker.  As  the  subject  is  so  thoroughly  handled 
by  him,  I  will  give  it  in  his  own  words: 

"To  secure  isotonicity  might  appear  an  easy  matter  at  first  sight, 
but  from  my  observations  is  not  so.  A  5  per  cent,  solution  of  stovain 
in  distilled  water  freezes  at  about  o.58°C.,  almost  the  same  point  as 
that  of  blood-serum.  If  this  were  the  only  test  applied  it  ought  to  be 


440  LOCAL   ANESTHESIA 

isotonic  with  the  blood.  But  if  a  drop  of  blood  be  added  to  a  little 
4  or  5  per  cent,  solution  of  stovain  under  the  microscope,  in  five 
minutes  the  red  corpuscles  swell  and  become  pale,  in  ten  minutes  are 
almost  invisible,  and  in  twenty  minutes  are  all  gone.  The  same  is 
seen  if  a  drop  of  blood  is  added  to  5  c.c.  of  these  solutions  in  a  test- 
tube;  but  here  the  changes  are  apparently  slower,  as  at  the  end  of  an 
hour  a  few  swollen,  pale  cells  can  still  be  seen,  but  in  an  hour  and  a 
half  they  are  all  invisible. 

"In  a  really  isotonic  fluid,  such  as  normal  saline  (0.91  per  cent, 
sodium  chlorid)  or  normal  glucose  solution  (5  per  cent,  of  glucose), 
the  cells  are  seen  in  twenty-four  or  forty-eight  hours  unchanged. 

"The  hemolytic  action  of  stovain,  which  I  have  tested  in  every 
way  I  could  think  of,  appears  hitherto  to  have  escaped  notice.  It  has 
been  supposed  too  readily  that  if  its  5  per  cent,  solution  has  the  same 
freezing-point  as  the  blood  it  would  be  isotonic  with  it,  but,  as  we  have 
seen,  the  blood-cells  are  destroyed  by  it.  Even  the  solution  prepared 
for  Bier,  in  the  belief  that  it  was  isotonic  (stovain,  4  per  cent. ;  sodium 
chlorid,  o.n  per  cent.;  epirenin  borate,  o.oi  per  cent.),  I  find  to  be 
markedly  hemolytic,  tested  as  above  on  the  microscopic  slide  and 
in  a  test-tube.  But  further  than  this  I  have  found  that  if  to  an  iso- 
tonic solution  of  sodium  chlorid  or  glucose,  in  which  blood-cells  are 
seen  to  be  unaltered  at  the  end  of  twenty-four  hours,  5  per  cent,  of 
stovain  be  now  added,  the  cells  rapidly  swell,  grow  pale,  and  disap- 
pear, no  trace  of  them  being  found  in  one  and  one-half  hours.  No 
combination  of  sodium  chlorid  or  glucose  with  stovain  which  I  have 
made  hitherto  has  prevented  this  hemolytic  action  of  the  drug. 

"Furthermore,  it  may  be  added  that  I  have  added  a  5  per  cent, 
solution  of  stovain  with  a  freezing-point  of — o.58°C.  to  an  equal  part 
of  cerebrospinal  fluid,  and  found  in  this  compound  destruction  of  all 
blood-cells  in  about  one  hour.  Nothing  is  seen  then  under  the 
microscope  but  debris  and  oily  globules.  This  is  as  much  as  to  say 
that  a  5  per  cent,  solution  of  stovain  injected  into  the  spinal  cord 
would  be  hemolytic  too. 

"Leaving  the  point  of  osmotic  tension  for  the  present,  and  admit- 
ting that  we  have  no  evidence  to  show  that  the  small  amount  of  the 
drug  injected  has  produced  any  injurious  effect  as  the  result  of  its 
hemolytic  action,  there  are  other  physical  qualities  which  an  injected 
compound  may  possess  which  also  appear  to  have  attracted  little  or 
no  attention. 

"There  are  three  ways  in  which  an  analgesic  fluid  injected  in  the 
second  lumbar  interspace  can  make  its  direct  effects  felt  in  the  mid- 


SPINAL  ANALGESIA  441 

dorsal  region,  or  even  higher,  as  is  sometimes  the  case  in  this  proced- 
ure. These  are  either: 

"(i)  By  slow  diffusion;  (2)  by  shifting  of  the  whole  column  of 
cerebrospinal  fluid,  in  which  it  is  suspended  upward;  or  (3)  by  gravita- 
tion, if  the  injected  compound  be  distinctly  heavier  than  the  liquor 
spinalis. 

"  i.  Diffusion  alone  of  one  fluid  in  another  is  a  slow  process,  and, 
as  we  shall  see,  is  unlikely  to  be  the  mode  of  spread  of  the  injected 
fluid  in  this  procedure. 

"2.  Bier  and  his  followers  have  aimed  at  shifting  the  injected 
compound  upward  or  downward,  with  the  whole  mass  of  the  cerebro- 
spinal fluid,  by  raising  or  depressing  the  pelvis.  That  the  cerebro- 
spinal fluid  does  recede  somewhat  toward  the  head  on  elevation  of 
the  pelvis  is  undoubted,  but  it  is  hard  to  imagine  its  doing  so  to  such 
an  extent  as  to  carry  with  it  a  cloud  of  fluid  lighter  than  itself  from 
the  second  lumbar  to  the  fifth  dorsal  vertebrae.  I  venture  to  think 
that  with  such  a  fluid  as  he  has  used,  whose  specific  gravity  is  1.0058, 
suspended  in  the  liquor  spinalis,  whose  specific  gravity  is  1.0079,  that 
what  he  has  achieved  by  elevation  of  the  pelvis  has  rather  been  a 
more  rapid  diffusion  of  the  injected  drug,  due  to  the  consequent  oscil- 
lation of  the  spinal  fluid,  aided  perhaps  by  vascular  pulsation. 

"3.  There  remains,  then,  the  third  possibility,  namely,  that  an 
injected  compound  heavier  than  the  liquor  spinalis  may  be  affected 
by  gravity,  and  sink  through  the  latter  in  a  way  quite  different  to  the 
behavior  of  a  fluid  of  less  specific  gravity  such  as  that  just  referred  to. 
It  is  easy  to  observe  the  behavior  of  one  fluid  injected  slowly  into 
another  through  a  needle  if  the  fluid  be  colored  with  anilin  blue. 
Provided  that  each  be  of  the  same  temperature  and  specific  gravity, 
the  injected  liquid  forms  at  first  a  distinct  blue  cloud,  which  slowly 
diffuses  itself  through  the  whole  mass,  into  which  it  enters  if  the  latter 
be  in  a  state  of  rest.  On  the  other  hand,  if  the  injected  fluid  be  of 
the  same  temperature,  but  of  much  greater  specific  gravity,  it  sinks 
rapidly  from  the  point  of  the  needle  in  a  definite  stream  to  the  bot- 
tom of  the  second  fluid,  and  remains  there  as  a  distinct  stratum, 
without  diffusion  for  a  time,  proportionate  to  its  density  and  viscidity. 

"The  densities  of  the  only  three  compounds  used  in  our  series 
compared  with  that  of  the  cerebrospinal  fluid  are  as  follows  at  15° 
to  i7°C.: 

"Liquor  spinalis  (from  three  patients,  mixed  fresh)  =   i .  0070 

1.  Chaput's  Compound:    , 

Stovain,  10  per  cent.;  NaCl,  10  per  cent.,  distilled   water,  80  per  cent.  =  1.0831 

2.  Writer's  Compound: 


442  LOCAL   ANESTHESIA 

Stovain,  10  per  cent.;  glucose,  5  per  cent.;  distilled  water,  85  per  cent.  =  1.0300 

3.  Bier's  Compound: 
Stovain,  4  per  cent.;  Nad,  o.u  per  cent.;  eperenin  bo  rate,  o.oi .  =  i  .0058 

"All  these  are,  as  we  have  seen,  more  or  less  hemolytic,  tested  by 
immersion  in  them  of  blood-cells,  the  first  much  the  most  so  (three 
minutes) ,  the  two  last  about  the  same  in  this  respect  (one  to  one  and 
one-half  hours) .  The  first,  a  very  heavy  fluid,  in  which  the  common 
salt  is  present  at  the  point  of  saturation  at  ordinary  temperature, 
has  long  been  used  by  Chaput  and  Tuffier  with  good  results,  but  ap- 
parently for  other  reasons  than  its  density.  Their  grounds  for  em- 
ploying such  a  high  percentage  of  common  salt,  as  stated  by  the 
former,  were  that  M.  Billon  (Paris),  who  prepared  the  compound  for 
them,  hoped  thereby  to  prevent  the  splitting  up  of  the  stovain  by 
the  alkalinity  of  the  spinal  fluid.  That  it  does  not  do  so  is  evident 
to  any  one  who  adds  some  of  their  compound  to  the  cerebrospinal 
fluid  drawn  off.  It  will  then  be  seen  that  the  latter  becomes  almost 
at  once  milky.  If  a  little  of  the  fluid  in  this  state  be  examined  under 
the  microscope  it  will  be  seen  that  this  turbidity  is  due  to  the  presence 
of  small  globules  of  an  oily  nature,  which,  in  the  course  of  time,  run 
together  into  larger  and  larger  globules. 

"A  solution  of  5  per  cent,  pure  glucose  in  distilled  water  freezes  at 
about  o.56°C.,  and  is  really  isotonic,  producing  no  effect  on  the  blood 
or  tissue  cells  in  twenty-four  hours.  Five  per  cent,  stovain  in  normal 
solution  gives  a  specific  gravity  of  1.0126.  The  hemolytic  action  of 
stovain  cannot  be  avoided. 

"  Alypin, 

5  per  cent.;  distilled  water,  95  per  cent.;  sp.  gr.,  1.0036;  freezing-point,  0.53 
Novocain, 

5  per  cent.;  distilled  water,  95  per  cent.;  sp.  gr.,  1.0090;  freezing-point,  0.555 
Tropococain, 

5  per  cent.;  distilled  water,  95  per  cent.;  sp.  gr.,  1.0160;  freezing-point,  0.545- 
Stovain, 

5  per  cent.;  distilled  water,  95  per  cent.;  sp.  gr.,  1.0064;  freezing-point,  0.585 
Cerebrospinal  fluid,  sp.  gr.,  1.0070;  freezing-point,  0.56 

Blood-serum,  freezing-point,  0.56 

"Drawing  conclusions  from  the  above,  these  fluids  should  behave 
differently. 

"  Tropacocain,  with  its  high  specific  gravity,  should  sink.  The 
uniformly  good  results  obtained  by  many  with  this  agent  may  be 
due  partly  to  its  physical  properties,  perhaps  more  so  than  to  any 
specific  action  on  nervous  structures.  Allowance  should  be  made 
for  the  behavior  of  any  fluid  after  injection  and  during  operation  on 
the  patient. 


SPINAL  ANALGESIA 


443 


"By  glass  tubes  bent  to  conform  to  the  spinal  canal,  filled  with 
salt  solution  (specific  gravity  1.0070),  and  having  an  opening  to  con- 
form with  the  position  of  the  second  lumbar  space,  the  action  of  dif- 


Fig.  119. — A  photograph  of  a  tracing  from  Braune's  well-known  plate  of  a  frozen 
mesial  section  of  the  female  cadaver  lying  level.  Details  omitted  for  the  sake  of  clear- 
ness. Over  the  spinal  canal,  and  following  its  curves  accurately,  is  a  glass  tube  filled 
with  saline  solution  of  the  same  specific  gravity  as  that  of  the  cerebrospinal  fluid  = 
1.0070.  Through  the  middle  vertical  arm  over  the  second  lumbar  interspace  the  hollow 
needle  has  been  introduced  into  the  curved  tube,  and  i  c.c.  of  Chaput's  solution  (specific 
gravity  1.0831)  colored  with  methyl-violet  has  been  slowly  injected.  This  has  run 
down  rapidly  into  the  dorsal  curve,  and  at  the  end  of  two  minutes  is  seen  as  a  dark  stra- 
tum opposite  the  fifth  and  sixth  dorsal  vertebrae.  The  dark  area  in  the  cervical  portion 
of  the  tube  is  a  shadow  on  the  glass.  (Barker,  in  "  Brit.  Med.  Jour.") 


Fig.  120. — Same  as  Fig.  119,  but  with  the  pelvis  raised  3  inches  from  the  level.  In 
this  case  i  c.c.  of  Bier's  solution  has  been  similarly  injected  colored.  This,  having  a 
specific  gravity  of  only  1.0058,  has  not  altered  its  position,  except  that,  being  lighter 
than  cerebrospinal  fluid  (1.0070),  it  has  risen  in  the  vertical  arm.  In  this  position  it 
remains  for  a  long  time  undiffused.  (Barker,  in  "  Brit.  Med.  Jour.") 

ferent  solutions  in  vitro  has  been  studied.  Of  course,  it  is  conceded 
that  certain  vital  phenomena  would  modify  the  conditions  some- 
what, but,  in  the  main,  what  occurs  here  furnishes  us  with  fairly 


444 


LOCAL  ANESTHESIA 


correct  evidence  on  most  of  the  scientific  physical  points  connected 
with  these  injections  in  the  living  patient  (Figs.  119-125). 

"Each  of  the  compounds  to  be  colored  with  the  same  quantity 
of  methyl-violet,  and  used  at  the  ordinary  temperature  of  the  air 
and  fluid  filling  the  tube.  It  has  been  gently  passed  into  the  latter, 


Fig.  121. — Three  tubes,  as  in  Figs.  119  and  120,  but  without  the  tracing  behind. 
Into  the  top  one  Bier's  light  solution  has  been  injected,  into  the  middle  tube  glucose 
stovain  (author's  solution,  specific  gravity  1.030x3),  and  into  the  lower  tube  Chaput's. 
The  pelvis  has  been  raised  3  inches  as  before.  In  the  top  tube  Bier's  compound,  being 
lighter  than  the  fluid  in  the  canal,  has  remained  stationary;  the  glucose-stovain  (1.0300) 
is  still  running  down.  Chaput's,  the  heaviest  compound,  has  already  reached  the  dor- 
sal curve  and  is  at  rest.  Photographed  two  minutes  after  injection.  (Barker,  in 
"Brit.  Med.  Jour.") 

as  on  the  living  patient,  with  the  usual  needle  through  the  vertical 
arm  over  the  second  lumbar  interspace.  From  frozen  sections  of 
the  cadaver,  lying  on  its  back,  it  may  be  seen  that  the  highest  point 
of  the  canal  from  the  level  is  in  the  cervical  region.  Next  to  this  a 
point  between  the  third  and  fourth  lumbar — that  is,  the  point  at 
which  the  puncture  for  spinal  analgesia  is  made.  From  this  last 


SPINAL  ANALGESIA 


445 


point  the  dural  canal  slopes  downward  in  both  directions.  The 
caudal  incline  ends  for  the  dura  opposite  the  third  sacral  vertebra. 
The  cephalic  incline  slopes  from  the  point  of  puncture  downward  as 
far  as  the  fifth  or  sixth  dorsal  vertebra,  when  it  begins  to  run  up  again 
to  reach  its  highest  point  at  the  third  cervical  vertebra.  With  the 
head  thrown  downward  on  a  pillow,  as  the  writer  believes  it  should 
always  be  during  intradural  injections  with  heavy  fluids,  the  foramen 


Fig.  122. — Sitting  position  for  puncture  when  analgesia  of  the  perineum  is  required. 
The  line  from  iliac  crest  to  crest  crosses  the  fourth  lumbar  spinous  process,  above  which 
the  needle  is  entered.  The  patient  is  then  gently  laid  on  his  back  with  the  head  and  neck 
well  raised,  all  unnecessary  movement  being  avoided.  From  a  photograph  by  Dr.  E. 
Worrall.  (Barker,  in  "Brit.  Med.  Jour.") 

magnum  would  be  the  highest  point  in  the  spinal  canal.  These 
curves  vary  considerably  in  individuals  and  at  different  ages,  but  the 
above  may  be  taken  as  generally  correct.  Now,  if  it  were  possible 
to  puncture  the  lumbar  sac  from  behind,  at  the  classical  point,  with 
the  patient  lying  on  the  back  perfectly  horizontal,  a  liquid  heavier 
than  the  spinal  fluid  would  always  flow  for  the  greater  part  from  the 
injection  needle  toward  the  dorsal  curve  and  settle  in  a  layer  about 


446 


LOCAL   ANESTHESIA 


the  fifth  dorsal  spine,  while  some  of  it  would  gravitate  toward  the 
caudal  end.     This  is  actually  what  happens  when  the  experiment  is 


Fig.  123. — Glass  tubes  accurately  bent  to  curves  of  spine,  and  filled  with  solution 
of  sodium  chlorid  of  the  same  specific  gravity  (1.0070)  as  that  of  the  cerebrospinal 
fluid.  A,  Sitting  position.  Tube  curved  to  the  line  of  the  dural  sac  from  occiput  to 
caudal  termination  (frozen  section,  Braun).  This  has  been  injected  with  i  c.c.  of  our 
heavy  analgesic  compound  (specific  gravity  1.0230)  of  the  same  temperature  as  the  solu- 
tion in  the  tube.  The  injection  was  previously  colored  with  i  per  cent,  methyl-violet. 
In  the  photograph  taken  two  to  three  minutes  later  it  is  seen  to  have  run  down  to  the 
sacral  sac  and  to  remain  unmixed  there.  In  the  living  subject  subsequently  laid  on  the 
back  it  would  again  flow  a  very  little  with  the  cerebrospinal  fluid  toward  the  head.  B, 
The  same,  quite  horizontal.  Shows  the  injection  pooled  in  the  dorsal  curve  two  minutes 
after  introduction  in  the  second  lumbar  space.  A  little  has  run  down  into  the  sacral  sac. 
Of  course,  the  patient  can  never  be  injected  actually  on  the  back  for  practical  reasons, 
c,  Tube  bent  to  a  tracing  of  the  lateral  curve  with  head  and  pelvis  raised  before  injec- 
tion, as  in  Fig.  1 24.  The  injection  is  seen  collected  in  a  pool  about  the  sixth  and  seventh 
dorsal  vertebras  two  minutes  after  introduction  through  the  second  lumbar  interspace. 
This  curve  is  greater  than  usual,  but  represents  what  increase  may  be  produced  in  it  by 
inclining  the  back  a  little  toward  the  operator  when  the  patient  lies  on  the  side,  as  in 
Fig.  124.  From  a  photograph  by  Dr.  E.  Worrall.  (Barker,  in  "Brit.  Med.  Jour.") 

made  with  the  glass  tube  bent  accurately  to  the  curves  of  the  spinal 
canal.     But  in  the  living  body  there  are  practical  difficulties  in  pene- 


SPINAL   ANALGESIA 


447 


trating  from  behind  with  the  patient  supine.  However,  if  the  injec- 
tion be  made  while  the  patient  lies  on  the  side  (or  face),  as  I  have 
occasionally  done,  and  he  then  turns  over  on  the  back  with  the  head 
thrown  forward,  a  heavy  fluid  should  take  the  same  course.  That 
it  does  so  is  almost  proved  by  the  regularity  with  which  the  analgesia 
produced  by  the  Chaput  heavy  saline  stovain-sodium-chlorid  com- 
pound or  the  writer's  stovain-glucose  one,  though  not  quite  so  heavy 
(see  above),  rises  to  about  the  episternal  notch  or  a  little  higher — 
that  is,  the  region  supplied  by  the  sixth  and  seventh  dorsal  nerves. 
This  varies  a  little,  according  as  the  head  and  neck  are  raised,  and  so 


Fig.  124. — Photograph  of  patient  in  typical  position  on  side,  with  head  and  neck 
raised  and  a  i-inch  padded  board  under  the  trochanter  and  iliac  crest.  The  line  of  the 
iliac  crests  is  given  crossing  the  fourth  lumbar  spine.  The  level  of  the  first  cervical  spine 
is  seen  to  be  well  above  that  at  which  the  injection  compound  "pools,"  and  will  be 
relatively  higher  when  the  patient  rolls  on  the  back,  as  in  Fig.  125.  From  a  photograph 
by  Dr.  E.  Worrall.  (Barker,  in  "  Brit.  Med.  Jour.") 


the  dorsal  curve  increases.  This  was  so  frequently  observed  in  the 
second  50  cases,  where  the  glucose-sto vain  compound  was  alone  used, 
as  to  be  remarkable.  Of  course  this  may  be  modified  somewhat  by 
raising  the  pelvis  a  little,  as  has  usually  been  done,  to  hasten  the  flow 
of  the  injected  fluid  toward  the  dorsal  curve  before  it  becomes  diluted 
by  diffusion.  It  must  not  be  forgotten,  however,  that  in  raising  the 
pelvis,  while  the  head  and  neck  are  supported  forward  on  a  pillow, 
the  lumbar  curve  is  diminished,  while  that  of  the  dorsum  is  increased. 
The  pelvis  would  have  to  be  raised  very  high  indeed  to  bring  the 


448  LOCAL   ANESTHESIA 

level  of  the  dorsal  curve  at  the  fifth  or  sixth  spine  above  that  of  the 
foramen  magnum,  with  the  head  and  neck  bent  forward,  as  described. 
There  is,  therefore,  but  little  likelihood  of  the  heavy  compound  reach- 
ing the  medulla,  or  even  into  the  cervical  region  at  all.  In  some  cases 
in  Germany,  inversion  has  been  carried  to  a  very  extreme  degree,  the 
head  being  unsupported,  with  the  idea  of  displacing  the  whole  mass 
of  the  cerebrospinal  fluid  toward  the  cranial  cavity.  But  we  must 
remember  that  in  these  cases  the  compounds  have  usually  been  of 
low  specific  gravity,  and  in  the  case  of  Bier's  (see  above)  actually 
lighter  than  the  spinal  fluid,  so  that  it  would  not  be  likely  to  move  as 
far  as  the  neck  by  any  oscillation  of  the  column  of  the  spinal  fluid. 
There  have  been  a  few  cases,  however,  both  in  France  and  Germany, 


Fig.  125. — Photograph  of  the  same  patient  gently  rolled  over  on  the  back  with  the 
same  relations  of  head,  neck,  and  pelvis.  The  line  across  the  fourth  lumbar  spine  is  seen, 
and  also  that  the  dorsal  curve  is  deeper  than  the  previous  lateral  curve.  From  a  photo- 
graph by  Dr.  E.  Worrall.  (Barker,  in  "Brit.  Med.  Jour.") 


in  which  the  analgesia  has  extended  over  the  whole  head,  as  well  as 
the  rest  of  the  body,  without  injury,  but  the  details  as  to  injection 
and  pelvic  elevation  are  not  given.  They  were  probably  instances 
of  diffusion  helped  by  oscillation.  Personally,  I  have  never  aimed  at 
getting  a  higher  analgesia  than  to  the  transverse  nipple  line.  At  the 
caudal  curve  the  effects  of  a  heavy  compound  can  be  limited  in  the 
same  way  by  position.  If  the  patient  be  seated  on  the  edge  of  the 
operating-table,  with  his  feet  on  a  low  chair  and  his  back  rounded, 
the  heavy  fluid  injected  at  the  second  lumbar  interspace  at  once 


SPINAL   ANALGESIA  449 

tends  to  run  into  the  sacral  dura,  as  we  see  also  in  our  tube  experi- 
ments. Here  it  accumulates  at  the  end  of  the  dural  sac,  where  it 
quickly  affects  the  roots  of  the  nerves  supplying  the  parts  about  the 
anus  and  the  perineum.  This  is  seen  so  constantly,  even  where 
analgesia  is  less  satisfactory  in  other  parts,  that  it  suggests  that  when 
the  injection  is  made  in  the  sitting  position  most  of  it  makes  its  way 
caudally,  and  it  requires  much  and  immediate  elevation  of  the  pelvis 
and  oscillation  of  the  cerebrospinal  fluid  to  dislodge  it  from  the  sacral 
sac.  That  is  why  I  have  thought  it  well  in  some  cases  to  puncture 
with  the  patient  lying  face  downward,  with  a  hard  pillow  crosswise 
under  the  umbilicus,  so  as  to  decrease  the  lumbar  curve.  In  this  posi- 
tion a  heavy  fluid  runs  toward  the  head,  and  if  after  half  a  minute 
the  patient  roll  over  on  the  back  and  have  a  pillow  placed  under 
the  head  and  neck  pretty  high,  the  injected  fluid  collects  in  the  lower 
dorsal  curve.  This  prone  position,  otherwise  desirable,  has  the  de- 
fect that  the  flow  of  cerebrospinal  fluid  is  not  so  good  unless  the 
patient  is  told  to  raise  his  head  and  to  bear  down,  but  I  think  this 
can  be  overcome.  But  so  great  is  the  tendency  for  the  injection 
fluid  to  be  in  part  locked  up  in  the  sacral  sac  when  the  injection  is 
done  in  the  sitting  position,  that  if  I  want  the  analgesia  to  reach  to 
the  border  of  the  ribs  for  an  abdominal  operation,  the  patient  is 
placed  on  the  side  with  the  knees  drawn  up  as  high  as  possible  for 
puncture,  and  thus  all  the  compound  flows  at  once  upward  and  all 
of  it  collects  in  the  dorsal  curve  as  the  patient  rolls  over  on  the  back. 
In  such  cases,  where  the  patient  remains  for  any  time  on  the  side 
after  the  puncture,  we  have  noticed  that  the  analgesia  reaches  higher 
up  at  the  end  of  the  operation  on  the  side  on  which  he  has  been  lying. 
This  seems  to  indicate  clearly  that  the  bulk  of  the  compound  has 
run  along  the  roots  on  that  side,  but  that  it  ultimately  becomes  seg- 
mental,  affecting  both  sides,  though  still  unequally." 

Dr.  Babcock,  of  Philadelphia,  who  has  had  extensive  experience 
with  spinal  analgesia  and  has  carried  out  some  original  investigations 
in  this  field,  reverses  the  procedure  of  Barker  and  uses  solutions  of 
lighter  specific  gravity  than  the  cerebrospinal  fluid,  using  alcohol  as 
the  means  of  accomplishing  this  purpose.  Stovain  is  the  agent  usu- 
ally employed,  and  is  put  up  in  sterile  ampules  containing  10  per 
cent,  alcohol. 

The  high  lumbar  puncture  is  usually  employed,  and  the  patient 
immediately  placed  in  the  inverted  or  Trendelenburg  position,  with 
the  idea  that  the  injected  fluid  being  lighter  will  float  upward  in  this 
position  toward  the  caudal  end  of  the  dural  sac. 


450  LOCAL   ANESTHESIA 

BABCOCK'S  SOLUTIONS 

Light  Solutions. 

A.  Stovain o.oSgm. 

Lactic  acid o .  04  c.c. 

Absolute  alcohol 0.2    c.c. 

Distilled    water...  .  1.8    c.c. 


B.  Tropacocain o.  i    gm. 

Absolute  alcohol 0.2    c.c. 

Distilled   water 1.8    c.c. 

C.  Novocain i .  16  gm. 

Absolute  alcohol 0.2    c.c. 

Distilled  water 1.8    c.c. 

Heavy  Solution. 

D.  Stovain 0.08  gm. 

Lactic  acid 0.4    c.c. 

Milk  sugar , o.  10  c.c. 

Distilled   water  to  make 2.0    c.c. 

These  solutions  are  kept  in  sealed  ampules  each  containing  2  c.c. 
They  are  prepared  under  rigid  aseptic  precautions  and  sterilized  by 
the  intermittent  method  at  a  temperature  not  to  exceed  65°C.  as 
boiling  caused  deterioration  of  the  anesthetic  to  which  is  attributed 
many  of  the  bad  effects. 

The  dose  for  an  adult  is  from  i  to  1.5  c.c.  Babcock  usually  pre- 
fers to  use  solution  A,  which  is  the  most  powerful  anesthetic,  the 
most  toxic  and  hemolytic,  B  and  C,  containing  tropococain  and  novo- 
cain,  are  less  active  and  less  toxic.  Solution  D,  the  heavy  solution,  is 
used  when  it  is  intended  to  keep  the  patient's  head  elevated. 

INDICATIONS  AND  CONTRA-INDICATIONS 

In  the  last  few  years  general  interest  in  spinal  anesthesia  has  con- 
siderably abated  and  it  is  much  less  frequently  resorted  to  than  for- 
merly. A  few  of  its  earlier  advocates  still  adhere  to  it  as  a  routine  and 
by  persistent  efforts  have  improved  their  technic  and  are  able  to  give 
a  more  favorable  mortality  report.  Notable  among  these  advocates 
are  Chassaignac,  Delaup  and  Babcock  who  collectively  have  had 
many  thousand  cases.  Babcock's  last  report  gave  over  6000  cases. 

The  opinions  of  these  men  who  have  had  extensive  experience  is  of 
much  greater  value  in  drawing  conclusions  than  scattered  reports  of 
a  few  cases.  While  undoubtedly  much  progress  has  been  made  in 
the  technic  and  in  the  results  obtained,  the  mortality  is  still  too  high 
to  recommend  it  as  a  method  of  choice.  Its  selective  field  of  influence 


SPINAL    ANALGESIA  451 

may  make  it  particularly  well  indicated  in  certain  conditions,  nota- 
bly those  associated  with  high  blood-pressure  as  no  other  anesthetic 
produces  such  complete  vasomotor  relaxation,  and  it  is  consequently 
contra-indicated  in  the  opposite  condition  of  hypotension. 

It  may  prove  of  decided  advantage  in  cases  of  aneurysm,  threat- 
ened decompensation  in  cardiac  disease,  in  the  high  tension  of  eclamp- 
sia, nephritis,  labor,  and  advanced  arteriosclerosis;  the  vasomotor 
relaxation  which  it  produces  may  prove  decidedly  protective.  For 
this  same  reason  it  lessens  the  tendency  to  hemorrhage  in  labor  and 
does  not  seem  to  favor  secondary  hemorrhage. 

Due  to  its  stimulating  action  upon  intestinal  peristalsis  it  is 
particularly  well  suited  to  certain  abdominal  conditions  in  which 
there  is  intestinal  distention  as  in  appendicitis.  In  these  cases  its 
power  to  increase  intestinal  peristalsis  by  paralyzing  the  inhibitory 
fibers  often  permits  the  immediate  emptying  of  the  bowel  while  on 
the  table,  producing  a  flaccid  and  relaxed  abdomen  which  greatly 
facilitates  the  operative  procedure.  In  paralytic  ileus  this  action  is 
so  marked  as  to  often  afford  immediate  relief.  Babcock  reports 
several  cases  of  this  condition  in  which  operative  intervention  had 
been  planned  and  in  which  the  relief  was  so  prompt  following  the 
spinal  injection  that  operation  was  unnecessary. 

In  the  above  conditions  associated  with  much  shock  it  should  be 
cautiously  used  and  may  be  inadvisable  in  extensive  peritonitis  as  it 
is  always  questionable  in  any  general  infection.  Within  the  abdomen 
its  use  should  be  confined  to  the  lower  portion  of  the  cavity,  as  it  is 
impossible  to  obtain  an  effective  anesthesia  of  the  upper  abdomen 
without  anesthetizing  the  lower  intercostals,  which  materially  em- 
barrasses respiration  and  profoundly  affects  the  blood-pressure.  It 
is  indicated  in  pronounced  alcoholics  and  may  prove  of  decided 
benefit  in  pelvic  neuroses,  vesical,  uterine,  prostatic  and  rectal  in 
much  the  same  way  as  the  epidural  injections  of  Cathelin.  While 
frequently  of  benefit  here  it  should  be  used  cautiously  as  neurotics 
are  prone  to  develop  an  increase  in  their  symptoms  or  the  addition 
of  others  from  any  disturbance  of  the  nervous  system  and  will  most 
probably  blame  the  operator  and  the  spinal  anesthesia.  It  has  been 
tried  empirically  in  herpes  zoster  and  in  sciatica  often  with  pro- 
nounced benefit. 

Spinal  puncture  has  been  demonstrated  to  be  irritating  to  the 
kidneys,  but  less  so  than  general  anesthesia;  it  may  consequently 
find  an  indication  here.  Its  use  in  diabetes  has  often  been  followed 
by  coma. 


452  LOCAL   ANESTHESIA 

In  shock  the  result  of  injury  to  the  lower  extremities,  spinal 
analgesia  would  theoretically  seem  to  be  indicated,  but  owing  to  its 
marked  tendency  to  seriously  depress  the  blood-pressure  it  should  be 
employed  with  great  caution  in  any  condition  of  shock  and  then  only 
when  the  patient  begins  to  react. 


Fig.  126. — Author's  simple  device  for  testing  movements  of  solutions  of  different 
specific  gravity  when  injected  one  within  the  other,  the  injected  solution  being  colored. 
Consists  of  two  sections  of  glass  tubing  connected  by  a  short  section  of  rubber  tubing. 

For  the  same  reason  it  should  never  be  employed  after  severe 
hemorrhage. 

J.  Blumfeld,  in  writing  on  the  subject,  states  the  following:  "The 
effects  of  spinal  anesthesia  in  minimizing  shock,  by  cutting  off 
peripheral  impulses,  will  probably  prove  its  great  claim  to  utility  in 
the  future.  There  is  no  reason  why  this  valuable  effect  should  not 
be  employed  in  conjunction  with  general  anesthesia.  The  extremely 
small  amount  of  general  anesthesia  that  need  be  administered  to  a 


SPINAL   ANALGESIA  453 

patient  who  has  been  subjected  to  stovain  reduces  any  risk  of  the 
general  anesthesia  to  a  minimum;  only  enough  need  be  given  to  in- 
sure absence  of  all  consciousness." 

Jonathan  M.  Wainwright,  of  Scranton,  Pa.,  in  his  Address  on 
Surgery  before  the  Medical  Society  of  the  State  of  Pennsylvania 
("Pennsylvania  Med.  Jour.,"  November,  1905),  makes  a  careful 
study  of  spinal  analgesia  and  other  anesthetics,  especially  in  their 
relation  to  shock.  He  concludes  from  experimental  evidence,  that  in 
conditions  where  (i)  shock  exists  ether  very  markedly  increases  the 
shock;  (2)  if  the  spinal  canal  be  injected  with  cocain  or  stovain, 
traumatism,  amputations,  etc.,  which  would  otherwise  cause  marked 
shock,  do  not  have  any  effect;  (3)  the  amounts  of  cocain  or  stovain 
needed  for  spinal  analgesia  do  not  have  any  systemic  effect  when 
absorbed  into  the  general  circulation;  (4)  the  fall  of  the  temperature, 
noted  in  some  cases  after  spinal  injection,  is  a  mechanical  effect,  and 
is  not  due  to  the  drug.  The  following  general  conclusions  are  also 
offered:  Ether  and  chloroform  are  much  more  dangerous  than  has 
formerly  been  supposed.  In  many  cases  of  shock,  ether  or  chloro- 
form will  cause  death,  even  without  an  operation.  They  should  not 
be  given  where  local  or  regional  anesthetics  are  at  all  practicable. 
In  all  conditions  in  which  respiration  is  seriously  embarrassed  such  as 
empyema,  hydrothorax  and  large  intrathoracic  growths  it  should  not 
be  employed.  It  is  contra-indicated  in  the  very  stout,  plethoric  and 
dyspneic,  nervous  and  hysterical  individuals,  the  aged  and  debilitated 
and  in  all  conditions  of  physical  and  mental  depression,  in  recent 
syphilis,  locomotor  ataxia  and  other  diseases  of  the  spinal  cord  and 
central  nervous  system  in  all  extensive  suppurating  processes,  high 
temperature  and  infectious  diseases.  While  as  a  rule  contra-indi- 
cated in  children,  in  favorable  subjects  it  may  be  used;  the  size  of 
the  child  and  general  robustness  rather  than  the  age  should  be  taken 
as  a  guide  and  the  dose  proportioned  according  to  the  weight. 

As  a  rule,  young  or  middle-aged  adults  of  robust  type  make  the 
best  subjects.  Jf  after  puncture  the  spinal  fluid  is  found  to  be  turbid, 
no  injection  should  be  made. 

TECHNIC 

Spinal  analgesia  demands  a  more  highly  developed  technic  and  a 
greater  degree  of  watchful  supervision  than  does  the  use  of  ether ;  here 
the  surgeon  is  both  anesthetist  and  operator.  For  this  reason  its  use 
by  those  in  situations  where  anesthetists  are  not  obtainable  may  be 
questionable  as  occasional  operators  may  not  possess  efficient  technic 
or  the  judgment  or  experience  necessary. 


454 


LOCAL    ANESTHESIA 


There  are  definite  limitations  placed  upon  our  means  of  combating 
dangerous  symptoms.  An  excessive  dose,  whether  absolute  or  rela- 
tive, as  in  the  case  of  idiosyncrasy,  is  more  immediately  and  hope- 
lessly fatal  than  in  the  case  after  ether  or  chloroform,  because  it 
cannot  be  antagonized'  by  mechanical  eliminative  means.  In  the 
treatment  of  emergencies  one  runs  the  danger  of  fatal  syncope  if  we 
sit  the  patient  up;  if  we  invert  him,  we  increase  the  toxic  action  on 
the  higher  centers  and  he  may  succumb. 

About  one  hour  before  the  administration  of  spinal  puncture  it  is 
advisable  to  give  a  hypodermic  of  a  small  dose  of  morphin  (%  or  ^ 


Hint,  for 

'tnbar  ftinctsrt. 


Fig.  127. — The  point  for  lumbar  puncture.     ("Keen's  Surgery.") 

gr.).  Many  observers  prefer  the  combination  of  morphin  and  scopo- 
lamin,  as  recommended  by  the  writer,  before  major  operations  under 
local  anesthesia.  By  this  method  the  bad  after-effects  are  much 
lessened  and  the  analgesic  effect  intensified  and  prolonged.  The  dose 
should  never  be  large  enough  to  produce  somnolence,  but  just  suffi- 
cient to  allay  the  fears  and  anxiety  of  the  patient  by  inducing  drowsi- 
ness and  indifference.  Morphin,  gr.  %  or  Y^  with  scopolamin,  gr. 
1  (so,  is  the  dose  recommended  by  the  writer.  Under  this  influence 
the  fear  and  psychic  influences  which  may  contribute  to  shock  are 
greatly  lessened  or  entirely  eliminated.  This  is  particularly  useful  in 


SPINAL   ANALGESIA  455 

nervous  patients  and  in  all  patients  for  amphitheater  work.  Coming 
before  large  crowds,  and  being  operated  in  the  conscious  state,  is 
bound  to  have  some  disturbing  effect  even  upon  the  most  stoical. 

Dr.  Fowler  has  recommended  }{Q  gr.  of  strychnin  a  quarter  of  an 
hour  before  the  puncture,  stating  that  it  lessens  shock,  respiratory, 
and  circulatory  disturbances.  While  this  method  is  theoretically 
good,  it  does  not  seem  to  have  found  much  favor,  and  it  would  seem 
better  to  use  the  morphin  and  scopolamin  as  above  suggested.  Their 
action  in  allaying  nervousness  and  excitement  in  the  patient,  and 
thus  arresting  psychic  influences,  operate  more  toward  lessening 
shock  than  stimulation  of  the  centers  with  strychnin. 

This  technic  should  vary  according  to  whether  you  are  using  an 
anesthetic  solution  lighter  or  heavier  than  the  cerebrospinal  fluid. 
The  selection  of  the  solution  will  depend  upon  the  part  of  the  body 
to  be  operated  and  consequently  upon  the  position  the  patient  is  to 
take.  As  the  majority  of  operators  rarely  use  the  method  for  opera- 
tions higher  than  the  lower  abdomen  it  is  likely  that  a  moderate 
Trendelenburg  position  will  be  used;  consequently  a  light  anesthetic 
solution  should  be  selected.  This  position  has  many  advantages  for 
spinal  anesthesia  and  it  is  probable  that  less  disturbances  occur  with 
it  than  when  the  head  and  shoulders  are  elevated  due  no  doubt  to 
it  favoring  the  maintenance  of  the  blood-pressure  in  the  higher  nerve 
centers  and  should  any  disturbance  occur  the  position  is  more  favor- 
able for  combating  it.  After  the  use  of  a  heavy  solution  it  may  be 
highly  dangerous  to  lower  the  head  and  shoulders  below  the  level  of 
the  hips.  If  a  light  solution  is  to  be  used  those  recommended  by 
Babcock  may  be  selected  and  under  conditions  where  a  heavy  solu- 
tion would  seem  desirable  those  suggested  by  Barker  have  much  to 
recommend  them.  By  using  solutions  either  distinctly  lighter  or 
heavier  than  the  cerebrospinal  fluid  you  can  more  easily  regulate  and 
control  its  movements  within  the  subarachnoid  space. 

As  the  spinal  cord  ends  at  the  second  lumbar  vertebra,  no  injec- 
tion should  be  made  above  this  point.  The  method  of  Jonnesco, 
which  we  regard  as  dangerous,  will  be  discussed  in  a  subsequent 
section.  Jonnesco's  method  is  not  necessary,  however,  to  obtain  high 
analgesia.  By  using  solutions  of  high  specific  gravity,  and  changing 
the  position  of  the  patient,  we  can  control  the  movements  of  the  solu- 
tion within  the  canal  and  secure  high  analgesia  if  desired. 

There  are  three  points  for  puncture,  as  ordinarily  practised — the 
intervals  between  the  second  and  third,  third  and  fourth,  and  fourth 
and  fifth  lumbar  vertebrae  (Fig.  127). 


456  LOCAL   ANESTHESIA 

The  interval  between  the  third  and  fourth  vertebrae  is  commonly 
known  as  Quincke's  point;  between  the  fourth  and  fifth,  as  Tuffier's. 

Also  to  determine  whether  the  injection  is  to  be  made  with  the 
patient : 

1.  Lying  on  the  side  and  remaining  subsequently  in  the  hori- 
zontal position; 

2.  Sitting  during  puncture,  with  subsequent  horizontal  position; 
or, 

3.  In  either  of  the  above,  with  subsequent  inverted  (Trendelen- 
burg)  position. 

The  larger  the  quantity  of  anesthetic  solution  used,  the  higher 
the  anesthesia. 

The  value  of  the  use  of  solutions  of  high  specific  gravity,  and 
controlling  their  action  within  the  canal,  is  amply  stated  by  Dr. 
Barker. 

The  positions  in  which  the  patient  is  placed  after  having  received 
the  injection  have  the  most  important  influence  upon  the  extension 
upward  of  the  anesthesia.  A  comparison  of  these  may  be  made,  tak- 
ing only  three  varieties  for  the  sake  of  brevity: 

1 .  Injection,  with  the  patient  lying  down  on  the  side  and  remain- 
ing horizontal; 

2.  Injection  in  the  sitting  posture,  the  patient  subsequently  lying 
on  the  back; 

3.  Injection  in  the  sitting  posture,  followed  by  elevation  of  the 
pelvis. 

With  the  first  of  these  we  find  the  lowest,  with  the  second  a  higher, 
and  with  the  third  the  highest  extension  upward  of  anesthesia. 

The  cause  of  the  difference  is  very  simple. 

If  the  horizontal  position  is  changed  into  the  sitting,  the  liquid 
cerebralis  runs  out  of  the  cranial  cavity  into  the  spinal  cord.  If  the 
patient  again  lies  down,  the  fluid  runs  back  once  more  into  the  skull. 
When  the  Trendelenburg  position  is  produced  a  still  larger  amount 
of  the  cerebrospinal  fluid  flows  toward  the  head.  Seeing  that  the 
analgesic  compound  injected  is  carried  with  the  spinal  fluid,  the  ex- 
tension of  the  analgesia  upward  or  downward  is  determined  by  the 
movement. 

"This  all  means  simply  that  the  heavy  fluid  containing  the  drug 
flows  from  the  highest  point  of  the  lumbar  curve  (point  of  puncture) 
to  the  lowest,  in  the  lateral  or  dorsal  depression,  by  virtue  of  the 
specific  gravity  (1.0230),  the  liquor  spinalis  (specific  gravity  1.0070) 
being  in  a  state  of  rest. 


SPINAL   ANALGESIA  457 

"But  if  any  other  proof  were  needed  of  the  behavior  of  our  heavy 
analgesic  fluid  in  the  canal,  it  is  furnished  by  those  cases  in  which 
we  have  kept  the  patient  on  the  side  from  before  the  injection  to  the 
end  of  the  operation,  without  any  change  of  position  at  all.  One  or 
two  cases  out  of  many  will  suffice:  It  was  necessary  to  amputate  a 
young  man's  lett  leg  below  the  knee.  He  was  laid  on  the  left  side, 
with  the  head  well  raised  on  pillows,  the  left  shoulder  resting  on  the 
table.  In  this  position,  which  was  not  altered  in  the  least  until  he 
left  the  table,  the  injection  was  done  in  the  second  lumbar  interspace. 
In  the  course  of  five  or  six  minutes  paralysis  of  sensation  was  absolute 
in  the  dependent  left  leg.  In  the  right  leg  sensation  was  never  lost  at 
all.  The  patient  was  quite  comfortable  throughout  the  amputation. 

"In  another  case  of  operation  for  varicose  veins  of  the  left  thigh 
and  leg  the  same  was  done  with  like  results.  Dr.  Henry  Head,  who 
was  present  and  was  kind  enough  to  test  the  phenomena  of  sensation 
and  motion  most  minutely,  stated  that  the  right  (upper)  thigh  and 
leg  remained  entirely  unaffected,  both  as  to  sensation  and  motion. 
This  can  only  be  explained  by  the  flow  of  our  heavy  analgesic  com- 
pound along  the  roots  of  the  lumbar  nerves  of  the  left  side  without 
any  diffusion.  It  certainly  was  not  augmented  by  diffusion,  as  the 
functions  of  the  other  limb  remained  unaffected  throughout.  It 
would  be  incorrect,  then,  to  call  this  medullary  anesthesia,  as  is  some- 
times done"  (Barker). 

In  operations  upon  the  petineum  Barker  uses  the  sitting  position; 
in  all  others,  the  injection  is  made  in  the  recumbent  position. 

Only  in  high  abdominal  operations  is  it  necessary  to  slightly  ele- 
vate the  pelvis,  so  that  the  fluid  will  more  readily  gravitate  toward 
the  dorsal  curve. 

Several  operators,  notably  Bier,  Braun,  and  Donitz,  have  spoken 
of  the  use  of  a  band,  which  is  placed  around  the  neck  sufficiently 
tight  to  produce  venous  congestion  of  the  head.  This  raises  the  in- 
tracranial  tension  and  forces  the  cerebrospinal  fluid  downward. 
After  its  removal  the  fluid  flows  back  again.  They  have  at  times 
resorted  to  this  procedure,  but  it  would  seem  superfluous,  and  not  at 
all  necessary,  as  an  adjunct  to  our  technic. 

If  the  injection  is  to  be  made  in  the  sitting  position  the  patient 
sits  on  the  side  of  the  table,  a  stool  being  provided  for  his  feet.  The 
elbows  are  placed  upon  the  knees,  with  the  head  and  shoulders  bent 
far  forward — the  scorcher  position — so  as  to  arch  backward  the  lum- 
bar regions  and  increase  the  interval  between  the  lumbar  spines. 

The  kind  of  needle  used  in  making  the  puncture  is  of  much  im- 


458  LOCAL   ANESTHESIA 

portance.  It  should  have  a  sharp  but  short  point;  if  the  point  is 
made  too  long  only  a  part  of  it  may  enter  the  membranes,  permitting 
the  escape  of  the  cerebrospinal  fluid,  causing  you  to  think  you  are 
well  within  the  sac,  but  may  slip  out,  or,  when  the  injection  is  made, 
only  a  part  of  it  may  enter  the  subarachnoid  space,  the  remainder 
escaping  extradurally  and  lead  to  a  failure  in  anesthesia  (Figs.  128 
and  134). 

A  long  sharp  point  may  also  produce  damage  to  the  cauda.  It  is 
preferable,  therefore,  that  the  needle  have  a  short,  sharply  beveled 
point,  and  be  from  3^  to  4  inches  long,  and  of  as  small  a  caliber  as 


Fig.  128. — Spinal  puncture  needle  (i)  compared  with  ordinary  needle  (2).  Note 
short,  sharply  beveled  point  on  spinal  needle;  this  is  the  same  type  of  needle  as  is  used 
for  reaching  the  branches  of  the  fifth  nerve  at  base  of  skull. 

possible  consistent  with  strength,  and  permitting  a  lumen  of  suffi- 
cient size  so  as  not  to  be  readily  choked. 

Some  use  a  cannula  for  making  the  injection,  which  is  passed 
down  the  lumen  of  the  needle  after  the  puncture  is  made,  thus  insur- 
ing the  entrance  to  the  subarachnoid  space;  this,  however,  does  not 
seem  necessary  and  increases  the  size  of  the  needle  (Figs.  129,  130). 

With  skill  and  care,  in  a  normal  subject,  no  great  difficulty  is  ex- 
perienced in  entering  the  sac.  Any  good  all-glass  syringe  will  answer 
for  making  the  injection.  An  all-metal  syringe  should  never  be  used, 
as  you  should  always  be  able  to  see  the  condition  and  watch  the 
movements  of  the  fluid  within  the  syringe. 

A  syringe  of  2  c.c.  capacity  is  ordinarily  sufficient;  but  if  you 
decide  to  use  the  cerebrospinal  fluid  as  the  solvent  medium  for  the 
dry  sterile  powder  previously  deposited  in  the  barrel  of  the  syringe, 
then  a  large  one,  up  to  5  c.c.,  is  to  be  preferred;  or,  if  it  is  preferred 
to  mix  the  anesthetic  fluid  within  the  syringe  with  an  equal  quantity 


SPINAL    ANALGESIA 


459 


of  cerebrospinal  fluid  before  final  injection,  as  practised  by  Bier  and 
Tuffier,  the  larger  syringe  should  be  selected. 

The  syringe,  needles,  etc.,  used  for  spinal  puncture  should  never 
be  used  for  any  other  purpose,  and  should  be  sterilized  by  boiling  in 
plain  water.  No  alkalis  or  antiseptics  should  be  used.  Alkalis  de- 
stroy the  anesthetic  agents,  and  a  small  dose  of  antiseptic  may  prove 
irritating  to  the  cord. 

The  site  of  puncture  should  be  prepared  by  cleansing  with  soap 
and  water  only,  or,  if  antiseptics  are  used,  they  should  be  carefully 
washed  away  before  making  the  puncture.  Tincture  of  iodin  may 
be  as  satisfactorily  used  here  as  elsewhere  for  sterilizing  purposes. 


Fig.  129. — Syringe  and  cannulas  for 
subarachnoid  anesthesia.  (According 
to  Barker.)  ("Keen's  Surgery.") 


Fig.  130. — Demonstrating  the  use  of 
the  inner  cannula  for  injection  into  the 
subarachnoid  space.  (According  to 
Barker.)  ("  Keen's  Surgery.") 


Before  beginning  everything  should  be  tested  to  make  sure  that 
it  is  in  perfect  working  order.  Sterile  water  should  be  injected 
through  the  needle  to  determine  if  the  lumen  is  freely  open,  as  well 
as  to  clear  out  any  possible  small  particles  of  metal  loosened  from 
its  lumen  during  the  process  of  sterilization. 

In  making  the  puncture  the  needle  may  be  used  alone  or  fitted 
to  an  extra  syringe,  which  will  serve  as  a  handle.  The  objective  site 
for  the  injection  is  the  midline  of  the  subarachnoid  space,  between 
the  two  divisions  of  the  cauda  equina.  Tf  the  needle  enters  on  either 
side,  its  point  may  enter  the  bundle  of  nerves  and  the  discharged 
solution  be  more  or  less  retained  among  them,  leading  to  one-sided  or 
unsatisfactory  anesthesia.  Some  operators  make  the  puncture  di- 


460 


LOCAL   ANESTHESIA 


rectly  in  the  middle  line,  between  the  spines  of  the  vertebra.  In 
this  position  it  is  more  difficult  to  avoid  the  bony  prominences  with 
which  the  needle  may  come  into  contact. 

An  easier  and  equally  reliable  method  is  to  enter  slightly  from 
the  side  (Figs.  131-133). 

The  point  of  puncture  having  been  decided  upon,  we  will  say  the 
interval  between  the  third  and  fourth  lumbar  vertebrae  (the  spine 
of  the  fourth  vertebra  lies  on  a  level  with  a  line  drawn  between  the 


Fig.  131. — Side  view  of  lumbar  punc- 
ture between  the  third  and  fourth  lum- 
bar vertebrae.  ("Keen's  Surgery.") 


Fig.  132. — Showing  flexed  posture  of 
patient  and  point  for  making  lumbar  punc- 
ture, i  cm.  to  the  side  of  the  median  line, 
and  between  the  third  and  fourth  lumbar 
spines.  ("Keen's  Surgery.") 


highest  points  of  the  iliac  crests),  the  finger  of  the  left  hand  is  placed 
on  the  spine  of  the  fourth  vertebra,  and  the  needle  entered  about 
y±  inch  to  the  right  and  just  below  the  highest  point  of  the  spine, 
directing  the  needle  slightly  upward  and  inward  at  such  an  angle 
that  after  penetrating  2^  or  3  inches  it  will  reach  the  dura  in  the 
midline.  The  distance  from  the  surface  to  the  dura  varies  within 
certain  limits,  according  to  the  stoutness  or  size  of  the  individual, 
but  it  is  usually  about  2^2  or  3  inches.  Before  making  the  punc- 
ture, it  is,  of  course,  desirable  to  render  the  skin  anesthetic,  either 


SPINAL  ANALGESIA 


461 


with  ethyl  chlorid  or  with  a  syringeful  of  weak  novocain  or  Schleich 
solution. 

After  the  skin  is  passed  very  little  sensation  is  felt  by  the  patient. 
Just  before  entering  the  canal  the  needle  is  felt  to  encounter  the  dense 
fibrous  ligaments  of  the  spine.  When  this  is  pierced,  no  further  re- 
sistance is  felt  and  we  feel  we  are  in  the  spinal  canal.  The  only  proof 
of  entering  the  subarachnoid  space  is  the  escape  of  cerebrospinal  fluid. 
If  this  does  not  escape  we  cannot  feel  that  we  are  properly  within  the 


Fig.  133. — Section  through  vertebral  column.     Needle  in  position  between  spines  of 
fourth  and  fifth  lumbar  vertebrae. 

membranes.  If  this  does  not  occur  we  may  advance  the  needle  a 
little  further,  but  we  should  be  careful  not  to  advance  too  far,  or  we 
may  completely  pass  through  the  subarachnoid  space  into  the  parts 
on  the  anterior  surface  of  the  canal.  The  failure  to  secure  a  proper 
entrance  within  the  membranes  may  be  due  to  their  flaccid  condition 
and  their  being  puslfed  forward  in  front  of  the  needle.  If  such  is 
the  case,  and  the  patient  is  asked  to  hold  his  breath  and  bear  down, 
the  membranes  become  tense  and  the  needle  will  enter  more  readily. 
If  now  the  fluid  does  not  escape,  and  we  feel  sure  we  are  within 


462  LOCAL   ANESTHESIA 

the  membranes,  the  failure  of  the  flow  may  be  due  to  the  needle  hav- 
ing become  plugged  during  its  passage  through  the  tissues.  Gentle 
aspiration  can  be  made  by  fitting  the  empty  syringe  to  the  needle. 
If  nothing  comes,  the  needle  had  better  be  withdrawn  and  re-inserted, 
either  in  the  same  interspace  or  in  another.  Should  only  blood  ap- 
pear and  no  cerebrospinal  fluid,  the  needle  had  better  be  withdrawn 
and  re-inserted,  care  being  taken  to  first  free  its  lumen  of  any  clots. 
Occasionally  the  flow  of  fluid  is  preceded  by  a  drop  of  blood,  which 
is  of  no  movement. 

The  plexus  of  veins  surrounding  the  membranes  are  more  numer- 
ous in  front  and  on  the  sides,  less  so  behind ;  the  escape  of  blood  with 
the  anesthetic  fluid  into  the  sac  is  one  of  the  causes  of  failure  in  anes- 
thesia as  well  as  a  possible  cause  of  after-trouble. 

After  the  subarachnoid  space  has  been  reached,  it  is  generally 
advisable  to  allow  a  quantity  of  cerebrospinal  fluid  to  escape  equal 
to  the  volume  of  anesthetic  fluid  to  be  injected.  Some  allow  the 
escape  of  much  more,  as  much  as  5  to  10  c.c.,  or  even  15  c.c.,  claim- 
ing to  have  less  unpleasant  after-effects  when  this  is  resorted  to,  but 
it  is  thought  best  not  to  allow  too  much  to  escape. 

Dr.  S.  P.  Delaup,  of  New  Orleans,  states,  "It  has  been  a  common 
observation  that  patients  with  a  high  spinal  pressure,  as  evidenced 
by  a  strong,  continuous  flow  of  the  cerebrospinal  fluid,  are  more 
powerfully  influenced  by  the  analgesic  solution  than  those  in  whom 
the  spinal  fluid  escapes  by  drops.  It  is  possible  that  the  diffusion 
occurred  too  rapidly  in  such  cases." 

The  syringe  containing  the  anesthetic  solution  is  now  fitted  to 
the  needle  and  very  slowly  injected.  The  injection  should  never  be 
made  rapidly,  but  always  slowly,  for  we  must  remember  that  the 
cerebrospinal  fluid  is  really  a  water  cushion  on  which  rest  the  brain 
and  cord,  and  any  shock  transmitted  to  it  will  traverse  throughout 
its  entire  extent.  The  point  of  puncture  is  sealed  with  sterile  ad- 
hesive plaster  or  cotton  and  collodion. 

After  the  puncture  and  injection  have  been  successfully  made 
anesthesia  sometimes  fails  to  set  in.  In  this  event  we  may  have 
resort  to  one  of  two  procedures — either  we  may  repeat  the  injection, 
provided  the  two  injections  will  not  exceed  the  safe  maximum  dose 
of  the  agent  employed,  or  we  may  resort  to  general  anesthesia  if  the 
case  is  suitable. 

It  is  usually  advisable  to  allow  the  patient  a  light  meal  before 
making  the  puncture,  the  same  as  before  any  other  major  procedure 
with  local  anesthesia.  They  stand  the  puncture  and  subsequent  op- 


SPINAL  ANALGESIA  463 

eration  better,  and  are  less  liable  to  be  disturbed  by  nausea  and  faint- 
ing while  on  the  table.  The  objection  to  this  is  that,  in  the  event  of 
failure  to  secure  the  needed  anesthesia,  it  may  prevent  the  adminis- 
tration of  a  general  anesthetic.  During  the  progress  of  the  operation, 
after  successful  puncture,  it  is  a  good  practice  to  allow  the  patient 
some  stimulating  drink— toddy,  coffee,  or  milk-punch. 

FAILURES 

They  average  about  9  per  cent.,  but  differ  greatly  with  different 
operators. 

This  includes  cases  of  complete  failure,  partial,  incomplete,  or 
unilateral  anesthesia,  and  short  or  delayed  anesthesias. 


Fig.  134. — Schematic  representation  of  proper  and  improper  kind  of  needle  punctur- 
ing membranes  of  cord,  showing  how  use  of  improper  needle  may  withdraw  cerebro- 
spinal  fluid  by  point  partially  entering  membranes,  but  permit  escape  of  most  of  injected 
fluid  outside  of  membrane. 

Failures  may  occur  even  when  every  detail  of  the  technic  is  care- 
fully carried  out  and  the  injection  is  apparently  successful.  Many  of 
these  cases  have  been  attributed  to  idiosyncrasy  on  the  part  of  the 
patient,  but  this  is  hardly  likely  to  be  the  case,  except  in  a  very  limited 
number  of  cases,  for  if  such  frequent  idiosyncrasies  existed  we 
would  have  more  failures  from  local  anesthesia.  It  is  more  than 
likely  due  to  some  technical  error  made  possible  by  anatomic  ab- 
normalities, an  imperfect  puncture  of  the  membranes,  the  lumen  of 
the  needle  only  partially  entering  them,  permitting  an  escape  of 
cerebrospinal  fluid,  but  when  the  injection  is  made  most  of  the  solu- 
tion escapes  extradurally  (Fig.  134),  or  may  have  become  entangled 
in  the  bundles  of  the  cauda  equina,  producing  only  partial  or  unilat- 
eral anesthesia,  due  to  the  puncture  being  made  too  laterally. 


464  LOCAL   ANESTHESIA 

The  agent  used  may  have  become  inert  through  oversterilization 
or  age. 

The  delayed  appearance  of  anesthesia  cannot  be  satisfactorily 
accounted  for.  In  some  few  cases  the  delay  has  been  as  long  as  half 
an  hour.  Hollander  reports  a  case  in  which,  after  three-quarters  of 
an  hour's  delay,  anesthesia  set  in. 

Schleich  and  other  observers  have  shown  that  the  admixture  of 
the  various  anesthetic  agents  with  blood  renders  them  inert.  This 
has  been  attributed  to  the  strong  alkalinity  of  the  blood,  but,  as  the 
cerebrospinal  fluid  is  also  alkaline,  failure  must  be  due  to  other  factors. 
It  may  be  that  the  wounding  of  a  vein,  permitting  an  escape  of  blood 
into  the  subarachnoid  space,  may  account  for  some  of  the  failures. 

IN  OBSTETRICS  AND  GYNECOLOGY 

Various  results  have  been  recorded  from  the  use  of  spinal  analgesia 
in  obstetric  work,  some  reporting  fairly  satisfactory  results,  while 
others  report  indifferent  results  with  numerous  failures.  It  has  been 
stated  by  those  whose  experience  qualifies  them  to  speak,  that  when 
once  labor  has  well  started  the  spinal  puncture  does  not  interfere  with 
the  uterine  contractions,  but  may,  if  it  ascend  high  enough  in  the  canal, 
lessen  the  power  of  the  abdominal  muscles,  and  thus  remove  a  val- 
uable aid  to  the  expulsive  power  of  the  uterus.  When  used  it  should 
be  the  aim  to  limit  its  action  to  the  pelvic  canal  and  perineum,  con- 
sequently low  puncture,  between  the  fourth  and  fifth  lumbar,  should 
be  used,  with  elevated  shoulders  following.  Its  particular  claim  in 
obstetrics  aside  from  its  facilitating  operative  delivery  is  that  it 
lessens  hemorrhage  and  reduces  cardiac  and  pulmonary  strain;  for 
these  reasons  it  finds  an  indication  in  cases  of  pulmonary  tuberculo- 
sis and  in  eclampsia  by  lowering  the  blood-pressure  while  favoring 
delivery  through  relaxation  of  the  perineal  muscles.  The  great  ob- 
jection is  that  the  analgesia  is  not  of  sufficient  duration  and  often 
passes  off  before  the  completion  of  labor,  but  when  successful,  aids 
greatly  in  the  relaxation  of  the  pelvic  outlet,  permitting  the  painless 
application  of  forceps  and  later  repair  of  the  perineum  when  neces- 
sary. It  is,  however,  not  a  method  for  routine  use  in  obstetrics,  but 
may  be  advisable  in  exceptional  cases.  If  used  only  for  its  action 
upon  the  pelvic  outlet,  this  can  be  obtained  safer  and  better  through 
sacral  anesthesia.  Abdominal  cesarean  sections  have  been  success- 
fully performed  under  its  action,  but  here  it  is  simply  abdominal 
surgery,  and  meets  with  the  same  success  and  is  governed  by  the 
same  conditions  influencing  other  abdominal  work  with  this  method. 


SPINAL   ANALGESIA  465 

The  same  may  also  be  said  of  abdominal  gynecologic  operations. 
Regarding  vaginal  operations,  we  have  shown  that  the  perineum  and 
external  genitals  are  particularly  favorable  for  spinal  analgesia;  their 
nerves  come  from  the  lowermost  portion  of  the  dural  sac.  Operating 
with  solutions  of  high  specific  gravity,  with  head  and  shoulders 
elevated,  there  should  be  little  danger  from  toxic  effects  upon  the 
higher  centers.  These  regions  are  the  first  to  feel  the  anesthetic 
effect  and  the  last  to  return  to  normal  sensation. 

If  spinal  analgesia  were  the  method  of  choice  this  would  be  a 
favorite  field  for  work;  but  we  must  accept  the  weight  of  the  evidence 
of  statistics,  and  admit  that  the  mortality  is  greater  even  under  the 
most  favorable  conditions.  If  general  anesthesia  is  positively  contra- 
indicated,  a  large  number  of  vaginal  operations  can  be  safely  and 
easily  performed  under  local  or  sacral  injections,  leaving  a  few  opera- 
tions, which,  if  necessary,  may  be  performed  under  spinal  analgesia. 

MILITARY  SURGERY 

Here  it  may  find  a  field  of  usefulness,  but  as  yet  no  opportunities 
have  arisen  where  it  could  be  put  to  practical  tests.  Military  sur- 
geons have  taken  different  views  on  the  subject.  The  great  danger 
would  be  that  the  absolutely  necessary  details  of  asepsis  may  be 
neglected.  This  is  more  likely  to  be  the  case  on  the  field. 

Dr.  Thomson,  in  the  "  Journal  of  the  Association  of  Military 
Surgeons,"  writes  as  follows: 

"Tropacocain  spinal  analgesia  has  its  place  in  military  surgery, 
especially  field  work  in  time  of  war,  because  it  offers  the  following  ad- 
vantages: (i)  It  obviates  the  necessity  for  the  storage  and  transpor- 
tation of  the  bulk  of  general  anesthetics.  (2)  Is  much  more  eco- 
nomical than  general  anesthesia.  (3)  The  immense  saving  of  time 
and  attention  in  its  administration.  (4)  The  saving  in  operative 
personnel,  dispensing  with  the  necessity  of  anesthetizers.  (5)  The 
saving  in  the  number  of  attendants  for  individual  patients — after 
operation  under  spinal  anesthesia  the  patient  does  not  require  such 
attention  as  under  general  anesthesia.  (6)  The  saving  of  a  number 
of  bearers — under  spinal  anesthesia,  patients  are  much  more  able  to 
assist  themselves.  (7)  Its  employment  on  the  field  of  battle,  at 
dressing  stations,  ambulance  stations,  etc.,  must  be  the  means  of 
relieving  much  suffering,  as  well  as  the  prevention  of  shock  from  pain, 
and,  at  the  same  time,  render  the  wounded  man  better  able  to  assist 
himself  to  reach  the  field  hospital." 

I  cannot  entirely  agree  with  all  of  the  above  conclusions.     The 


466  LOCAL   ANESTHESIA 

preparation  and  sterilization  of  the  solution  and  the  technic  of  its 
administration  must  be  accurate  and  done  only  by  those  who  have 
knowledge  and  experience  in  this  branch  of  anesthesia.  The  wounded 
on  the  field  of  battle  are  often  badly  shocked  or  have  suffered  from 
hemorrhage,  two  distinct  contra-indications  to  its  use.  If  improp- 
erly used,  the  bad  after-effects  are  likely  to  give  the  surgeons  and 
attendants  much  more  work  than  its  advantages  can  save.  The 
equipment  and  methods  of  all  military  organizations  must  be  uniform 
and  it  would  seem  impossible  that  spinal  anesthesia  could  form  any 
part  of  them.  We  hear  nothing  of  it  in  the  great  struggle  now 
taking  place  in  Europe. 

PHYSIOLOGICAL  ACTION 

When  the  anesthetic  solution  is  injected  into  the  dural  sac  it  falls 
or  ascends  according  as  its  specific  gravity  is  greater  or  less  than  that 
of  the  cerebrospinal  fluid.  The  retention  of  the  anesthetic  within 
any  given  area  of  the  cord  is  accomplished  by  the  position  of  the 
patient  and  the  use  of  light  or  heavy  solutions  as  explained  above. 
The  results  of  the  injection  are  of  two  kinds:  the  immediate  due  to  the 
toxic  action  of  the  drug  on  the  nerves  and  their  centers ;  and  the  late, 
the  irritating  results  of  the  injection,  the  sequelae.  As  a  rule,  the 
bad  effects  increase  in  number  and  severity  the  higher  the  analgesia 
and  the  larger  the  dose  used.  Our  aim  should  be  to  find  an  anesthetic 
agent,  combination,  or  technic  which  will  leave  the  heart's  action, 
vascular  pressure  and  respiration  uninfluenced.  The  blood-pressure 
and  respiration  are  the  two  most  reliable  guides  to  the  condition  of 
the  patient.  As  the  injected  solution  rises  or  falls  it  comes  into  con- 
tact with  the  nerve  roots,  sensory  and  motor,  arresting  their  power  of 
conductivity,  producing  sensory,  sympathetic  and  motor  paralysis 
in  the  segments  affected.  The  centers  and  columns  in  the  cord  it- 
self are  only  superficially  influenced  and  may  continue  their  function. 
As  the  loss  of  pain  sense  is  much  greater  than  that  of  touch  the  patient 
may  continue  to  feel  the  knife  although  the  incision  is  not  painful. 
The  loss  of  sensation  and  motion  indicates  the  more  profound  action 
of  the  drug  and  is  greater  with  such  agents  as  stovain  and  less  with 
weak  drugs  like  novocain. 

In  the  great  majority  of  cases  the  onset  of  analgesia  is  without  any 
noticeable  disturbing  effect  upon  the  patient,  and  generally  begins  to 
make  itself  felt  in  from  three  to  five  minutes,  sometimes  longer,  being 
ushered  in  by  a  sense  of  numbness  or  tingling  in  the  lower  extremities. 
Analgesia  appears  first  in  the  external  genitals,  perineum,  and  inner 


SPINAL   ANALGESIA  467 

side  of  thighs,  then  progresses  down  the  limbs  and  up  toward 
Poupart's  ligament  or  higher,  depending  upon  the  point  of  puncture, 
position  of  patient,  volume  and  strength  of  the  agent  used.  It  ex- 
tends always  to  a  higher  level  posteriorly  than  anteriorly  on  the  trunk, 
owing  to  the  general  direction  of  the  spinal  nerves. 

The  return  of  sensation  is  in  inverse  order  to  its  development, 
disappearing  first  in  the  parts  last  affected  and  last  in  the  perineum 
and  external  genitals. 

The  duration  is  from  about  three-quarters  of  an  hour  to  an  hour 
and  a  half;  tropacocains Jightly  shorter  than  cocain  or  stovain. 

As  anesthesia  develops  the  reflexes  begin  to  disappear.  Some 
muscular  incoordination  is  usually  seen,  and  usually  more  or  less 
paresis  of  the  lower  extremities — sometimes  complete  paralysis.  The 
motor  disturbances  are  always  more  marked  with  stovain,  hence  its 
danger  in  high  analgesias,  where  it  may  paralyze  respiration. 

Tactility  is  usually  not  affected,  except  by  large  doses,  which 
paralyze  all  sensation. 

The  symptoms  vary  much  with  the  size  of  the  dose  as  well  as  in 
different  individuals.  By  using  only  the  smallest  efficient  dose  many 
of  the  unpleasant  symptoms  will  be  avoided. 

Occasionally  analgesia  is  ushered  in  by  muscular  twitchings  of  the 
lower  extremities,  more  or  less  violent;  slight  weakness,  nausea  or 
vomiting  may  occur,  or  sweating  may  be  noticed.  As  a  rule,  there  is 
not  much  difference  in  the  pulse  in  low  anesthesia.  In  a  few  cases 
the  above  symptoms  are  most  markedly  associated  with  symptoms  of 
collapse.  The  respiration  may  at  first  be  rapid,  labored,  or  sighing, 
becoming  more  shallow  later;  the  pulse  becomes  rapid  and  feeble. 
The  patient  may  be  seized  with  a  feeling  of  terror  or  be  so  collapsed 
as  to  be  indifferent.  Respiration  may  cease  entirely  and  death  be 
imminent. 

The  muscular  relaxation  of  the  anesthetized  parts  will  depend 
upon  whether  the  anesthetic  fluid  has  reached  the  anterior  roots  of 
the  spinal  cord,  and  varies  with  the  different  solutions  used — always 
more  markedly  with  stovain. 

VASCULAR  SYSTEM 

Following  the  phenomena  of  anesthesia  the  most  notable  effects 
are  upon  the  circulation  and  are  in  proportion  to  the  height  and  inten- 
sity of  the  action.  If  the  upper  dorsal  segments  are  reached  the 
phenomena  are  quite  marked  and  the  pulse  rate  may  drop  to  40  or 
30  and  the  blood-pressure  at  the  wrist  almost  to  zero.  This  results 


468  LOCAL  ANESTHESIA 

through  the  paralysis  of  the  vaso-motors  of  the  splanchnic  area  and 
the  paralysis  of  the  intercostals  limiting  the  thoracic  movements; 
the  aspirating  influence  upon  the  vena  cavae  is  lessened  and  the  heart 
fills  more  slowly.  The  drop  in  blood-pressure  lessening  the  intra- 
cardiac  pressure,  the  normal  stimulus  to  vigorous  action  is  lost.  The 
vagi  which  are  unaffected  exert  their  full  inhibitory  action.  Bier 
and  Zur  Verth  have  studied  the  blood-pressure  on  a  large  number  of 
cases  and  often  noted  a  fall  of  25  per  cent.  A  few  whiffs  of  ether  was 
found  to  augment  the  heart's  action  without  affecting  the  blood- 
pressure.  Adrenalin  used  alone  raised  the  blood-pressure  if  the 
heart  was  acting  normally  but  if  weakened  it  reduced  its  energy,  and 
as  the  blood-vessels  are  contracted  at  the  same  time  its  action  was 
more  that  of  a  general  collapse  of  the  whole  cardiovascular  system. 
That  this  collapse  does  not  regularly  occur  as  a  rule  is  due  to  some 
special  counteracting  influence  of  some  component  of  the  suprarenal 
preparations  acting  directly  on  the  heart  function.  When  symptoms 
of  collapse  are  marked,  the  patient  may  be  anxious  and  excited  or  so 
apathetic  as  to  be  oblivious  of  the  surroundings.  The  respirations 
are  coincidently  embarrassed  due  to  paralysis  of  the  intercostals  and 
the  anemia  of  the  respiratory  centers,  and  the  skin  is  cold  and  clammy 
with  a  profuse  perspiration. 

The  best  procedure  in  collapse  is  undoubtedly  saline  infusion  and 
this  should  be  slowly  and  cautiously  given.  Stimulants  should  be 
administered  by  hypodermic  needle  at  the  same  time,  caffein,  oil 
of  camphor,  strychnine,  digitalis  preparations  and  adrenalin.  If 
preferred  they  can  be  injected  into  the  infusion  solution  by  inserting 
the  needle  into  the  lumen  of  the  tube  close  to  the  patient.  If  adrena- 
lin is  used  it  should  not  exceed  20  minims  slowly  injected  as  an 
initial  dose,  more  may  be  needed  later,  and  when  combined  with 
infusion  we  have  the  conditions  present  for  its  favorable  action  which 
may  not  be  apparent  when  used  alone.  Parsons  reports  that  in 
several  cases  of  collapse  following  novocain  and  cocain  used  intra- 
spinally  that  light  ether  inhalations  proved  of  immediate  and  marked 

benefit. 

RESPIRATION 

The  direct  effect  upon  the  respiratory  muscles  depends  upon  the 
assent  of  the  anesthesia;  with  paralysis  of  the  lower  dorsal  segments 
respiration  becomes  embarrassed  mechanically  and  the  action  is 
largely  diaphragmatic,  but  without  the  aid  of  the  accessory  abdomi- 
nal muscles.  Respiration  is  also  affected  in  another  way  by  the 
tremendous  fall  in  the  blood-pressure  resulting  from  the  vaso-motor 


SPINAL   ANALGESIA  469 

paralysis  lessening  the  blood-supply  to  the  respiratory  centers  which 
may  often  be  carried  to  a  degree  which  arrests  their  function.  As  the 
degree  of  vaso-motor  involvement  is  always  proportional  to  the  as- 
sent of  anesthesia  along  the  cord  it  is  always  profound  when  the 
lower  dorsal  segments  are  involved. 

The  best  method  to  combat  respiratory  failure  or  embarrassment 
is  undoubtedly  artificial  respiration  which  should  be  carried  out  by 
the  best  means  available,  a  pulmotor  or  the  Sylvester  method,  or  as 
suggested  by  Babcock,  a  large  rubber  tube  may  be  passed  into  the 
trachea  through  which  the  surgeon  blows  his  own  breath  withdraw- 
ing his  lips  for  expiration  and  continuing  this  process  rhythmically. 
In  the  event  of  impending  death,  respiration  ceases  before  circulation, 
and  artificial  means  should  be  persisted  in  until  after  the  heart  stops 
beating  and  even  then  it  may  be  possible  to  revive  the  patient  by 
continuing  the  efforts.  Coincident  with  the  artificial  respiration 
infusion  and  stimulation  should  be  instituted  as  recommended  under 
"Vascular  System." 

ABDOMEN 

The  effect  of  a  spinal  injection  upon  the  abdominal  contents  de- 
pends entirely  upon  the  degree  of  ascent  of  the  anesthesia  and  is  most 
marked  when  the  lower  dorsal  segments  have  been  reached;  to  obtain 
anesthesia  of  the  entire  abdominal  wall  it  is  necessary  that  the  anes- 
thesia reach  the  sixth  dorsal  segment.  The  most  notable  effect  upon 
the  abdomen  is  the  completely  relaxed  and  flaccid  condition  of  the 
abdominal  wall  and  the  active  peristalsis  and  vigorous  contractions 
noticed  in  the  intestines,  which  often  results  in  copious  evacuations 
upon  the  operating- table,  which  is  facilitated  by  the  relaxed  sphincter. 
Intestinal  distention,  if  it  exists,  is  usually  immediately  relieved.  The 
stomach  participates  to  some  extent  in  this  increased  peristalsis  and 
should  nausea  occur  vomiting  is  difficult  unless  the  head  is  lowered, 
owing  to  the  paralysis  of  the  abdominal  muscles.  This  effect  upon 
the  intestines  results  from  paralysis  of  the  sympathetic  nerves,  the 
source  of  inhibition,  leaving  the  pneumogastric  and  nerve  plexuses 
within  the  intestinal  walls  unopposed  in  exercising  full  stimulation. 
As  a  result  of  this  double  effect  in  relaxing  the  abdominal  walls  and 
contracting  the  intestines  all  operative  manipulations  within  the 
cavity  are  greatly  facilitated.  This  full  effect  is  not  obtained  without 
a  marked  fall  of  blood-pressure  due  to  the  paralysis  of  the  vasomotors 
with  a  dilatation  of  the  large  venous  trunks,  and  if  the  anesthesia 
has  involved  the  lower  dorsal  segments  decidedly  embarrassed  respi- 
ration which  may  proceed  to  a  dangerous  extreme. 


470  LOCAL   ANESTHESIA 

Uterus. — Low  lumbar  injections  with  the  solution  held  in  the 
caudal  end  of  the  dural  sac  do  not  seem  to  materially  influence  uterine 
contractions  when  used  during  labor,  but  as  the  lower  abdominal 
muscles  are  more  or  less  affected  the  loss  of  this  normal  voluntary 
aid  retards  the  progress  and  does  not  seem  compensated  for  by  the  re- 
laxation of  the  pelvic  outlet,  and  due  to  the  absence  of  pain  there  is 
not  the  usual  stimulus  to  induce  the  woman  to  bear  down  even  if 
she  retains  some  control  over  her  abdominal  muscles.  High  injec- 
tions arrest  all  uterine  contractions.  Due  to  the  greatly  lowered 
blood-pressure  uterine  hemorrhage  following  labor  and  during  curet- 
tage  for  abortion  is  decidedly  less  than  under  general  anesthesia,  and 
the  after-contractions  of  the  uterus  are  not  apparently  retarded. 
Postpartum  hemorrhage  is  not  more  frequent  than  that  following 
other  methods. 

McCardie  gives  the  following  statistics,  gathered  from  the  large 
clinics : 

"In  23,955  cases  of  spinal  analgesia,  collected  from  forty  observers, 
there  were  29  deaths,  or  one  in  every  826.  Strauss  collected,  30,000 
cases,  with  i  death  to  1800  cases.  At  another  time  he  said  that 
tropacocain  had  a  record  of  7059  cases,  with  5  deaths,  or  i  in  1411. 
Hochmeier  and  Konig,  when  speaking  of  the  present  position  of 
spinal  anesthesia,  collected  from  many  hospitals  and  clinics  2400 
cases,  with  12  deaths,  or  i  in  200.  Hochmeier  concludes  that  spinal 
analgesia  should  only  be  used  when  ether-rausch  and  local  anesthesia 
will  not  suffice,  and  there  is  marked  centra-indication  to  general 
anesthesia." 

AFTER-EFFECTS 

About  one-third  of  the  cases  have  slight  headache  and  nausea, 
coming  on  within  an  hour  or  two  after  the  injection  and  passing  off 
within  a  iew  hours.  Slight  elevation  of  temperature  (about  ioo°F.) 
is  usual,  but  subsides  in  a  few  hours. 

In  a  small  percentage  of  cases,  2  or  3  per  cent.,  the  headache  is 
quite  severe,  and  in  some  may  become  quite  unbearable  and  last  for 
five  or  six  days  or  longer.  Occasionally  the  temperature  rises  quite 
high,  sometimes  reaching  io4°F.,  and  may  require  a  day  or  two  to 
subside.  The  pulse  may  become  rapid  and  weak  and  profuse  sweat- 
ing occur.  Collapse  may  come  on  immediately  or  is  sometimes  de- 
layed for  from  a  few  hours  to  several  days  after  the  puncture.  More 
marked  symptoms  of  meningeal  irritation  (meningismus)  may  appear, 
with  headache,  stiffening  of  the  muscles  of  the  back  and  neck,  which 


SPINAL   ANALGESIA  471 

may  persist  for  several  days,  associated  often  with  disturbances  of  mo- 
tion and  sensation  in  the  lower  extremities.  These  cases  may  clear 
up  in  a  few  days  or  go  on  to  the  development  of  purulent  meningitis. 

Vertigo,  more  or  less  persistent,  is  occasionally  observed.  The 
writer  had  a  case  in  which  the  vertigo  lasted  for  six  weeks.  The 
patient  was  almost  unable  to  walk  during  this  time. 

The  character  of  after-symptoms  may  vary  greatly,  and  are  by  no 
means  regular  as  to  kind  or  time  of  onset. 

Guinard's  observations  upon  patients  who  had  been  operated 
upon  under  spinal  puncture  showed  that  in  those  suffering  from  bad 
after-effects  there  was  a  marked  rise  in  the  pressure  of  the  cerebro- 
spinal  fluid,  as  demonstrated  by  a  second  puncture,  and  the  symp- 
toms were  relieved  by  allowing  the  escape  of  10  to  20  c.c.  of  fluid. 

Patients  who  showed  no  after-symptoms  were  found  to  have  no 
change  in  the  pressure  of  the  cerebrospinal  fluid. 

Ravaut  and  Aubourg  found  in  disturbed  cases  a  great  number  of 
leukocytes  in  the  spinal  fluid,  but  no  bacteria.  In  cases  that  were 
not  disturbed  the  appearance  of  the  fluid  and  its  tension  were  not 
changed. 

This  aseptic  puriform  condition  of  the  cerebrospinal  fluid  is  met 
with  in  other  conditions.  It  has  been  reported  occurring  with  otftis 
media,  syphilis,  and  many  suppurative  conditions.  When  encoun- 
tered in  the  course  of  spinal  puncture,  it  should  be  a  contra-indication 
to  further  procedure  and  the  injection  should  not  be  made. 

The  possibility  of  hemorrhage  within  the  dural  sac,  the  result  of 
the  puncture  wounding  some  small  vessel,  must  also  be  considered 
as  a  cause  for  the  after-effects  in  some  cases.  When  it  is  remembered 
how  often  the  puncturing  needle  withdraws  blood,  it  is  not  unlikely 
that  complications  from  this  cause  occur  oftener  than  is  suspected. 

The  simple  tapping  of  the  spinal  canal  for  purposes  of  examina- 
tion has  at  times  been  followed  by  after-effects  similar  in  kind,  though 
usually  less  severe,  than  those  we  are  accustomed  to  see  following 
spinal  analgesia.  The  experiments  of  Guinard  and  Kozlowski,  and 
later  confirmed  by  Stolz  and  Schwarz,  show  that  the  intraspinal  in- 
jection of  sterile  water,  or  even  normal  salt  solution,  is  followed  by 
after-disturbances.  Any  change  in  the  tonicity  of  the  cerebrospinal 
fluid  will  cause  a  change  in  the  cerebrospinal  pressure,  lowering  or 
raising  it  accordingly  as  hypo-  or  hypertonic  solutions  are  used. 

Clinically,  we  are  well  familiar  with  the  symptoms  of  increased 
cranial  pressure  the  result  of  other  causes.  While  the  immediate 
after-effects  are  undoubtedly  toxic,  it  is  claimed  by  some  observers 


472  LOCAL   ANESTHESIA 

that  many  of  the  later  after-effects,  such  as  secondary  headaches, 
vertigo,  stiffness  of  the  muscles  of  the  back  and  neck,  abducens 
palsy,  etc.,  are  the  result  of  the  use  of  contaminated  or  decomposed 
solutions.  These  debatable  points  can  only  be  settled  by  time. 

Babcock  reports  a  case  who  was  operated  eleven  times  by  spinal 
puncture  without  bad  results. 

EXPERIMENTAL  WORK 

The  introduction  of  spinal  analgesia  has  stimulated  experimental 
work  within  the  spinal  canal,  and  investigators  have  tested  the  effects 
of  various  substances  introduced  into  the  canal.  The  introduction 
of  sterile  water  has  been  found  to  produce  disturbances  of  motion, 
but  affecting  sensation  very  little.  Sicard  has  injected  dogs  weigh- 
ing about  20  or  30  pounds  with  200  c.c.  of  5  per  cent,  salt  solution 
and  produced  marked  disturbances  in  motility,  but  it  disturbed  sen- 
sation only  slightly. 

Within  the  last  five  years  some  improvement  has  occurred  in  the 
results  obtained  from  spinal  anesthesia  and  a  vast  addition  made 
to  the  clinical  experience  on  the  subject,  but  remarkably  little  on 
the  experimental  or  physiological  aspects  of  the  subject.  The  im- 
mediate danger  following  spinal  analgesia  may  occur  as  a  result  of 
paralysis  of  the  respiratory,  bulbar  vasomotor  and  other  higher  cen- 
ters, but  what  is  more  common  is  a  paralysis  of  the  efferent  nerve- 
fibers  which  control  the  blood-pressure  in  the  splanchnic  area  and 
may  lead  to  an  immediate  and  profound  fall  in  the  blood-pressure  in 
these  areas  and  the  patient  literally  bled  to  death  by  dilatation  of  the 
great  venous  trunks.  Smith  and  Porter  show  that  rabbits  can  be 
bled  to  death  within  their  portal  system  by  a  section  of  the  splanchnic 
nerves.  A  sudden  and  profound  fall  in  the  general  blood-pressure 
produced  by  this  result  may  so  exsanguinate  the  "master  cells"  in 
the  medulla  and  leave  them  insufficiently  supplied  with  oxygen  as 
to  produce  the  most  serious  consequence.  The  higher  the  puncture 
is  made  the  greater  the  danger  of  these  results,  for  this  reason  the 
high  dorsal  and  cervical  punctures,  which  at  one  time  were  tried, 
should  now  be  permanently  abandoned  in  the  present  stage  of  devel- 
opment of  this  method  and  these  injections  should  be  confined  to  the 
lumbar  region. 

In  considering  the  limited  laboratory  findings  available,  it  is 
probable  that  many  deaths  reported  as  due  to  paralysis  of  the  respira- 
tory centers  from  the  drug  having  reached  this  level,  were  in  reality 


SPINAL  ANALGESIA  473 

due  to  splanchnic  paralysis  and  vasomotor  collapse  lowering  the 
blood-pressure  within  these  parts  to  a  point  incompatible  with  life. 

It  would  certainly  be  ideal  if  a  drug  were  found  capable  of  paralyz- 
ing alone  the  afferent  sensory  paths  in  the  cord,  but  drugs  cannot 
differentiate  between  nerve-tissue,  and  the  efferent  vasomotor  fibers 
must  inevitably  feel  this  influence. 

According  to  the  results  of  Smith  and  Porter,  the  bulk  of  the  solu- 
tion seemed  to  be  of  greater  importance  than  its  strength — diluted 
solutions  as  a  rule  spread  further  than  concentrated  ones. 

The  work  of  Smith  and  Porter  has  proved  extremely  valuable  and 
shows  that  in  the  safe  use  of  spinal  anesthesia,  we  must  seek  only  to 
paralyze  the  afferent  sensory  paths,  without  a  too  pronounced  effect 
upon  the  efferent  vasomotors,  and  that  any  rational  surgical  prog- 
ress with  this  method  must  be  in  this  direction. 

Oelsner  and  Kroner  report  the  experiences  at  Sonnenburg's  clinic 
and  the  results  of  considerable  experimental  research.  They  experi- 
mented with  injections  of  salt  solution  cooled  to  freezing-point,  after 
withdrawal  of  a  corresponding  amount  of  cerebrospinal  fluid.  The 
ice-cold  fluid  does  not  injure  the  tissues,  while  the  anesthetic  effect 
justifies,  they  say,  further  trials  of  this  method;  especially,  they  add 
in  conclusion,  as  none  of  the  methods  of  spinal  anesthesia  in  vogue 
to  date  are  entirely  free  from  possible  evil  effects,  and  never  can  be 
free  from  them,  as  they  are  based  on  the  introduction  of  a  foreign 
chemical  substance  which  must  inevitably  do  more  or  less  injury. 

That  the  immediate  effects  are  not  due  to  the  systemic  action  of 
the  drug,  but  to  its  extension  upward  and  direct  action  on  the  higher 
centers,  is  amply  illustrated  by  the  following  experiments  of  Dr. 
Ryall: 

"Two  possibilities  at  once  strike  us  when  we  come  to  consider  the 
causation  of  respiratory  paralysis :  (i)  Are  they  the  results  of  reab- 
sorption  of  the  drug  into  the  general  circulation?  or  (2)  are  they 
caused  by  the  ascension  of  the  analgesia  solution  in  the  dural  sac  and 
the  direct  contact  with  the  vital  centers  in  the  cerebral  nervous  sys- 
tem? We  know  that  the  rapidity  of  the  reabsorption  of  drugs  dis- 
solved in  the  cerebrospinal  fluid  of  dogs,  on  account  of  the  activity  of 
the  reabsorption  surfaces,  is  generally  much  more  rapid  than  that 
of  the  subcutaneous  cellular  tissues.  The  same  amount  of  poison  has 
a  much  more  toxic  action  in  subdural  than  it  has  in  subcutaneous 
injections. 

"That  the  extension  of  the  drug  in  the  dural  sac  is  the  essential 
cause,  and  that  the  reabsorption  into  the  circulation  is  quite,  or  for 


474  LOCAL   ANESTHESIA 

the  greater  part,  irrelevant,  is  proved  by  the  following  experi- 
ments: 

"i.  When  novocain,  in  the  same  dose  (0.03  gm.  per  kilogram 
body-weight)  and  same  concentration  is  injected  into  rabbits,  we  find 
(a)  in  intradural  injections  there  is  always  at  once  intense  and  per- 
sistent fall  of  the  blood-pressure  and  frequently  death  within  a  few 
minutes;  (6)  in  intravenous  injections  there  is  an  immediate  fall  of 
the  blood-pressure,  but  it  is  of  very  short  duration,  and  death  only 
supervenes  if  the  injection  has  been  made  with  great  rapidity;  (c)  in 
intramuscular  injections  there  is  no  action  on  the  blood-pressure 
which  can  be  recognized.  From  this  comparison  one  must  draw  the 
conclusion  that  in  subdural  injections  the  reabsorption  of  the  poison 
cannot  possibly  be  the  only  cause,  and  never  the  chief  cause,  of  the 
poisoning.  For  no  matter  how  rapidly  it  may  be  sucked  up  out  of 
the  dural  sac  and  reabsorbed  from  the  subcutaneous  cellular  tissue 
and  muscular  system,  the  intensity  of  the  action  must  still  remain  far 
behind,  as  compared  with  the  immediate  flushing  of  the  circulation 
with  the  poison,  such  as  takes  place  in  intravenous  injections,  and 
yet  we  see  much  more  severe  and  prolonged  poisoning  which,  more- 
over, runs  an  entirely  different  course  in  intradural  injections.  This 
fact  can  only  be  explained  thus:  that  the  course  of  the  poisoning  in 
intradural  injections  is  characteristically  not  caused  through  the 
rapidity  of  the  reabsorption,  but  through  the  direct  action  of  the 
poison  on  the  substance  of  the  central  nervous  system.  It  is  only 
after  contact  with  the  central  organs  that  the  course  of  the  poisoning 
becomes  impressed  with  the  characteristic  stamp. 

"2.  In  a  second  series  of  experiments  the  dural  sac  was  closed 
before  the  injection  was  given  by  means  of  a  ligature  encircling  the 
membranes  and  cord  at  the  height  of  the  upper  thoracic  portion  of 
the  spine.  When  0.03  gm.  of  novocain  per  kilogram  body-weight  was 
injected  subdurally  below  the  ligature  (which  under  normal  circum- 
stances would,  without  exception,  cause  a  violent  fall  of  the  blood- 
pressure,  and  which  frequently  resulted  in  the  death  of  the  animal) 
the  blood-pressure  did  not  alter  at  all.  Injections  of  the  same  dose 
above  the  ligature  generally  killed  the  animal  at  once."  Similar 
experiments  were  undertaken  and  like  conclusions  drawn  by  Heneicke 
and  Laiven. 

We  know,  through  the  experiments  of  Aducco  and  Mosso,  that  a 
drop  of  concentrated  solution  of  cocain  deposited  on  the  floor  of  the 
fourth  ventricle  will  cause  the  immediate  death  of  the  animal. 

Klapp's  experiments  on  dogs  showed  that  the  addition  of  oil  to 


SPINAL   ANALGESIA  475 

the  solution  of  cocain  entirely  abolished  all  symptoms  of  intoxica- 
tion. When  the  cocain  was  in  an  oily  vehicle,  total  anesthesia  could 
be  induced  in  the  dog  without  the  slightest  symptoms  of  intoxication. 

We  know  that  in  the  use  of  oily  solutions  of  anesthetics  locally 
the  anesthetic  effect  is  greatly  prolonged,  owing  to  the  inability  of 
the  lymphatics  to  take  up  the  oil,  and  the  danger  of  toxemia  thus 
greatly  lessened,  but  the  method  has  other  disadvantages  and  has 
never  found  favor. 

When  used  in  the  spinal  canal,  if  the  solution  was  permitted  to 
come  in  contact  with  the  higher  centers,  the  danger  would  be  just 
as  great  as  with  watery  solutions,  or  probably  more  so,  as  it  would 
take  longer  for  the  oily  solution  to  be  removed  by  absorption;  and 
oily  solutions,  being  ordinarily  lighter  than  the  cerebrospinal  fluid, 
would  be  expected  to  float  upward. 

The  danger  in  spinal  analgesia,  as  has  been  shown,  is  not  that  of 
general  toxemia  through  absorption,  for  the  dose  is  always  within 
safe  limits,  but  for  its  local  action  on  the  vital  nerve-centers. 

The  addition  of  small  quantities  of  gum  arabic  to  the  analgesic 
solution  has  been  experimented  with  by  some,  who  claim  for  it  that 
it  does  not  interfere  with  the  anesthetic  action,  but  minimizes  the 
dangers  by  preventing  absorption  by  the  higher  centers;  this,  how- 
ever, is  unlikely.  It  no  doubt  owes  any  advantage  it  possesses  to 
its  greater  specific  gravity,  thus  keeping  the  solution  away  from  the 
higher  centers. 

But  if  anything  of  its  kind  is  to  be  used,  it  is  far  better  to  use 
glucose,  which  is  normally  a  constituent  of  certain  parts  of  the  body; 
this  is  advocated  by  Barker,  and  referred  to  at  length  elsewhere. 

Of  considerable  interest  was  the  discovery  by  Meltzer  of  the 
anesthetic  effects  of  magnesium  salts  when  injected  into  the  spinal 
canal.  Meltzer  first  experimented  on  monkeys,  and  found  it  to  be 
a  motor  and  sensory  paralysant.  In  one  animal  he  injected  what 
would  have  been  a  lethal  dose.  In  twenty-five  minutes  respiration 
had  ceased.  Tracheotomy  was  done  and  artificial  respiration  was  in- 
stituted. The  heart,  which  had  nearly  stopped  through  asphyxia, 
now  regained  its  force  and  rate.  Artificial  respiration  was  continued 
for  seven  hours,  but,  as  there  was  no  effort  on  the  part  of  the  animal 
to  resume  its  own  respiration,  it  was  continued  for  seven  hours 
longer,  the  heart  during  this  time  acting  perfectly.  At  the  end  of 
this  time  spontaneous  respiration  was  resumed.  The  animal  re- 
covered completely  and  was  apparently  in  good  condition. 

This  experiment  seemed  to  prove  conclusively  that  death  is  due 


476  LOCAL   ANESTHESIA 

to  paralysis  of  respiration  alone,  the  heart  apparently  not  being 
affected. 

Meltzer  found  that  0.06  gm.  per  kilogram  was  not  dangerous  in 
monkeys.  He  suggested  one-third  this  amount  to  be  used  on  man, 
giving  i  c.c.  of  a  25  per  cent,  solution  of  magnesium  sulphate  to 
each  25  pounds  body-weight.  Following  these  suggestions,  opera- 
tions were  performed  under  its  use,  and  it  was  used  for  a  time  ex- 
tensively in  tetanus,  both  by  spinal  injection  and  by  hypodermocly- 
sis;  but,  while  it  controlled  the  convulsions  often  for  twenty-four 
hours  at  a  time,  the  high  temperature  characteristic  of  this  disease 
continued  and  the  patients  succumbed  from  exhaustion,  without 
there  being  any  gain  in  the  reduction  of  the  mortality.  The  method 
was,  accordingly,  discontinued  as  offering  no  advantage. 

Canestro  experimented  with  it  on  dogs,  using  adrenalin  in  addi- 
tion, and  confirmed  Meltzer's  observations.  He  stated  that  it  was 
free  from  irritating  effects  on  the  tissues,  and  could  find  no  histologic 
changes  in  the  nervous  system  or  kidneys. 

URINARY  CHANGES 

Numerous  observations  made  on  the  urine  show  that  spinal  anal- 
gesia is  irritating  to  the  kidneys.  Albumin  and  casts  have  frequently 
been  noted,  but  of  short  duration.  The  changes  may  appear  in  a 
few  hours  or  be  delayed  several  days,  disappearing  a  few  days  later. 
No  permanent  changes  or  no  fatal  results  from  renal  effects  have 
been  recorded. 

All  the  agents  used  may  show  this  effect;  stovain  slightly  more  so. 

As  compared  with  the  renal  changes  following  anesthesia,  Tomas- 
chewski  gives  60  per  cent,  for  spinal  analgesia  compared  to  72  per 
cent,  for  general  anesthesia.  He  also  states  that  66  per  cent,  of 
major  operations  under  local  anesthesia  show  slight  traces  of  albumin. 

Csermak,  in  a  study  of  60  cases  with  stovain,  gives  39  in  which 
the  urine  remained  normal.  Albumin  appeared  in  12;  albumin  and 
a  few  white  blood-cells  in  6 ;  albumin  and  granular  casts  in  2 ;  albumin, 
granular  casts,  and  white  blood-cells  in  i. 

Hartleib,  in  making  similar  observations,  found  stovain  to  pro- 
duce albumin  in  78  per  cent,  of  cases;  in  20  cases  with  tropacocain 
only  i  showed  albumin.  These  observations  have  been  amply  con- 
firmed by  others. 

In  a  study  of  35  cases  Gellhorn  reports  acetonuria  in  33,  it  ap- 
peared within  from  eight  to  twenty-four  hours  and  lasted  usually 


SPINAL   ANALGESIA  477 

five  to  six  days,  in  i  case  as  long  as  fourteen  days.  No  bad  effects 
were  attributed  to  this  symptom. 

The  urinary  excretion  immediately  following  the  injection  is 
materially  lessened,  due  to  the  general  fall  in  blood-pressure,  but  this 
effect  is  transient  and  is  quickly  recovered  from  with  the  return  of 
blood-pressure  to  normal. 

While  spinal  anesthesia  does  excite  certain  functional  disturbances 
in  the  kidneys,  in  Babcock's  experience  it  seems  well  suited  to  all 
kidney  and  bladder  surgery  and  he  states  that  he  has  repeatedly 
operated  both  kidneys  at  the  same  time  without  untoward  results. 
Few  operators  would  care  to  assume  this  risk. 

EFFECTS  ON  THE  NERVOUS  SYSTEM 

Many  observations  and  experiments  have  been  made  to  show  the 
effect  of  spinal  analgesia  upon  the  spinal  cord  and  nerves  within  the 
canal.  Nearly  all  of  these  investigations  were  with  stovain.  We 
know  that  stovain  affects  both  motor  and  sensory  nerves,  also  that 
it  is  irritating.  Necrosis  has  at  times  been  noted  following  its  use 
locally.  Prolonged  paralysis,  at  times  ending  in  death,  has  been 
recorded  following  its  use.  It  was  consequently  to  be  expected  that 
nerve  changes  should  occur.  They  are,  however,  in  the  great  ma- 
jority of  cases,  transient.  These  findings  emphasize  the  great  dan- 
ger of  using  spinal  analgesia  in  patients  suffering  from  diseases  of 
the  nervous  system. 

Reynier  reported  a  case  of  syncopal  collapse  in  a  patient  the 
evening  after  an  operation  under  spinal  anesthesia.  She  revived 
under  prompt  artificial  respiration.  In  another  case  unbearable 
pains  in  the  leg,  commencing  a  week  after  the  operation,  persisted  for 
a  week.  In  another  case  a  fracture  of  the  malleolus  had  been  reduced 
under  spinal  anesthesia  without  mishap.  A  month  later  the  man  was 
affected  with  complete  paralysis  of  the  arms,  legs,  and  back  of  the 
neck.  He  could  not  hold  his  head  erect  or  turn  it;  the  head  dropped 
back  whenever  it  was  passively  lifted.  He  was  like  a  jumping-jack 
whose  strings  have  all  been  cut.  As  there  were  no  sensory  disturb- 
ances, hysteria  was  out  of  the  question.  The  paralysis  gradually  sub- 
sided, and  he  left  the  hospital  in  apparently  normal  condition  at  the 
end  of  two  weeks.  Reynier  has  also  heard  complaints  from  patients 
that  they  could  not  walk  so  well  as  before  their  operation  under 
spinal  anesthesia.  Guinard  was  one  of  the  first  and  most  enthusi- 
astic adherents  of  spinal  anesthesia,  but  he  stated  that  he  had  com- 
pletely abandoned  it  since  his  experience  in  3  cases.  In  the  first  a 


478  LOCAL   ANESTHESIA 

woman  of  fifty  passed  successfully  through  a  vaginal  hysterectomy. 
Three  months  later  she  developed  paresis  of  the  legs,  with  inconti- 
nence of  urine  and  feces,  and  died  with  symptoms  of  softening  of  the 
brain  within  the  year;  this  result  also  occurred  in  a  second  case.  In  a 
third  case  the  patient  died  suddenly  three  weeks  after  a  simple  suture 
of  a  perineal  laceration  under  spinal  anesthesia. 

Incontinence  of  urine  and  paralysis  of  the  anal  sphincter  have 
frequently  been  observed,  more  frequently  the  former.  They  usually 
require  no  special  treatment  other  than  providing  for  the  discomfort, 
as  they  usually  clear  up  in  a  few  days. 

That  some  of  the  later  after-effects  may  be  due  to  causes  other 
than  the  puncture  and  injection  is,  of  course,  possible,  but  the  reports 
of  these  cases  are  too  numerous  to  leave  any  doubt  that  the  great 
majority  are  the  direct  results  of  the  spinal  analgesia. 

Gangrene  has  frequently  been  reported  as  occurring  in  various 
parts  of  the  lower  extremities  and  buttocks. 

Spielmeyer  has  examined  the  central  nervous  system  in  13  cases 
dying  after  spinal  analgesia.  In  i  case  death  was  the  result  of  the 
puncture,  the  patient  dying  forty  hours  after,  the  other  12  cases 
dying  of  other  causes  following  operation.  In  all  cases  stovain  was 
used. 

The  changes,  for  the  most  part,  consisted  in  degeneration  of  the 
motor  ganglion  cells  of  the  anterior  horn,  and  were  seen  low  down 
and  high  up  in  the  cord.  In  some  the  changes  were  so  pronounced 
that  they  would  seem  to  be  irreparable,  but  that  none  of  these  changes 
were  discovered  in  cases  where  the  dose  did  not  exceed  0.9  gr.  In 
the  case  dying  as  a  result  of  the  puncture,  1.7  gr.  had  been  used. 
Here  paralysis  of  respiration  had  been  the  first  sign  of  trouble.  His 
experiments  on  dogs  gave  the  same  results;  when  small  doses  were 
used,  no  change  could  be  detected. 

Klost  and  Vogt's  experiments  agree  with  Spielmeyer.  They 
found  chromolysis  in  some  of  the  anterior  motor  cells.  Direct  in- 
jections of  the  anesthetics  into  the  substance  of  the  cord  further  con- 
firmed their  toxic  action.  When  normal  salt  solution  was  used  in- 
stead of  the  anesthetic  solution  no  changes  were  observed,  showing 
that  they  were  not  of  mechanical  origin. 

Wossidlo  and  Lier's  investigations  were  equally  as  interesting, 
and  agree  in  the  main  with  the  experiments  of  others.  Wossidlo 
concludes  that  tropacocain  was  less  dangerous  than  stovain  or  novo- 
cain,  but  that  their  effects  were  not  serious  enough  to  prevent  the 
use  of  the  drugs  in  this  method. 


SPINAL   ANALGESIA  479 

Particularly  interesting  and  thorough  were  the  investigations  of 
Spiller  and  Leopold,  which  I  quote  as  follows: 

"The  technic  of  our  experiments  consisted  in  performing  lumbar 
puncture  on  five  dogs,  with  careful  avoidance  of  infection.  The 
stovain  solution  used  on  dogs  D  and  E  was  boiled.  The  dose  of  each 
stovain  injection  varied  from  0.05  to  0.2  gm.,  and,  except  in  dogs  A 
and  B,  in  each  of  which  only  one  injection  was  given,  the  injections 
were  usually  at  intervals  of  two  or  three  days. 

"The  symptoms  may  be  divided  into  the  temporary  and  the  per- 
manent. The  temporary  consisted  of  flaccid  paralysis  and  complete 
or  partial  sensory  loss.  The  hind  limb  showed  flaccid  paralysis,  while 
the  entire  body  frequently  showed  the  loss  of  sensation,  implicating 
even  the  ear.  Bladder  and  rectal  control  was  lost,  and  the  tendon 
reflexes  were  either  diminished  or  absent.  These  symptoms  oc- 
curred immediately  or  several  minutes  after  the  injection  was  given, 
and  persisted  from  one  to  several  hours. 

"The  permanent  symptoms  consisted  of  ataxia,  decreased  sensa- 
tion, and,  in  dog  E,  loss  of  patellar  reflex.  The  symptoms  became 
permanent  after  the  third  injection,  remaining  until  the  end  of  the 
experiment.  The  ataxia  was  recognized  by  the  irregular  gait,  and 
the  tendency  to  stand  with  the  hind  legs  well  apart  and  the  peripheral 
part  of  the  hind  limbs  well  on  the  ground. 

"Axis-cylinders  in  the  periphery  of  the  anterolateral  and  posterior 
columns  were  found  here  and  there  considerably  swollen;  some  were 
of  large  size;  swollen  axis-cylinders  were  seen  in  the  root  entrance  of 
the  posterior  columns,  but  otherwise  not  in  the  posterior  columns  ex- 
cept near  the  periphery.  A  moderate  degree  of  cellular  reaction  to 
the  stovain  was  detected  in  the  pia  and  roots  of  the  cord  in  the  form 
of  round-cell  infiltration,  but  never  as  cells  of  polynuclear  type. 
This  is  not  a  surprising  finding,  and  resembles  what  is  seen  in  tabes. 
One  would  expect  some  cellular  reaction  to  a  poison  affecting  the 
nervous  system  as  does  stovain.  A  very  slight  perivascular  round- 
cell  infiltration  was  seen  here  and  there  in  the  cord;  it  was  so  slight 
as  to  be  of  no  importance,  and  its  existence  was  disputable.  The 
swelling  of  the  axis-cylinders  in  the  anterior  and  posterior  roots  was 
very  distinct,  and  the  swelling  affected  most  of  these  axis-cylinders. 
One  forms  the  impression  that  the  axis-cylinders  were  more  swollen 
in  the  anterior  than  in  the  posterior  roots. 

"The  posterior  columns  in  the  lumbar  region  were  degenerated, 
as  shown  by  the  Marchi  method,  throughout  a  transverse  section, 
but  much  less  so  in  the  ventral  zones.  The  reflex  collaterals  were 


480  LOCAL   ANESTHESIA 

also  much  degenerated,  and  the  degenerated  fibers  could  be  traced 
forward  into  the  anterior  horns.  Small  black  dots  were  found  along 
some  of  the  anterior  roots  within  the  spinal  cord,  and  this  finding 
indicates  a  moderate  amount  of  degeneration  here.  A  slight  degen- 
eration was  found  by  the  Marchi  method  along  the  periphery  in  the 
anterolateral  columns;  it  was  far  less  intense  than  in  the  posterior 
columns.  In  the  thoracic  region  the  degeneration  of  the  posterior 
columns  was  confined  to  the  columns  of  Goll;  the  columns  of  Burdach 
seemed  to  be  intact.  The  degeneration  of  the  anterolateral  columns 
in  the  thoracic  region  was  insignificant.  The  lumbar  sections  were 
taken  fully  i%  to  2  inches  above  the  point  of  injection. 

"Anterior  and  posterior  roots,  taken  between  the  dural  cavity 
and  the  posterior  ganglia,  were  teased  in  the  fresh  state  and  stained 
with  a  i  per  cent,  aqueous  solution  of  osmic  acid.  They  presented 
considerable  degeneration,  chiefly  in  the  form  of  minute  black  gran- 
ules within  the  neurilemma  sheaths,  and  the  degeneration  was  more 
advanced  in  the  anterior  roots.  One  could  not  conclude  from  this 
finding  that  stovain  affects  the  anterior  roots  more  than  the  posterior; 
rather,  the  finding  would  seem  to  imply  that  the  roots,  having  been 
affected  by  the  stovain  within  the  dural  sac,  secondary  degeneration 
would  be  found  in  the  portion  of  the  anterior  roots  examined,  and 
retrograde  degeneration  in  the  portion  of  the  posterior  roots  examined. 
Nerve-roots  taken  from  within  the  interior  of  the  dural  canal,  unfor- 
tunately, were  not  examined  by  this  method. 

"The  nerve-fibers  in  one  of  the  lower  spinal  ganglia,  placed  in  the 
tresh  state  in  i  per  cent,  osmic  acid  solution,  showed  intense  degen- 
eration of  the  fine  granular  variety.  The  cells  of  the  ganglion 
presented  little  degeneration. 

"A  nerve  taken  from  the  hind  leg  appeared  intensely  degenerated 
when  placed  in  the  fresh  state  in  osmic  acid. 

"It  seems  clearly  demonstrated  that  stovain  affects  especially 
the  anterior  and  posterior  roots;  the  degeneration  of  posterior  root- 
fibers  in  our  sections  was  intense.  What  is  worthy  of  note,  the 
degeneration  of  the  intramedullary  portion  of  the  lumbar  and  sacral 
posterior  root-fibers  in  the  thoracic  region  was  still  intense.  The 
posterior  thoracic  roots  were  unaffected.  Stovain  evidently  also 
causes  slight  degeneration  in  the  periphery  of  the  anterolateral  col- 
umns, but  has  less  effect  here  than  on  the  nerve-roots. 

"These  lesions  obtained  by  us  could  not  have  been  produced  by 
the  trauma  of  the  needle,  as  the  sections  of  the  lumbar  region  ex- 
amined were  i^  to  2  inches  above  the  point  of  injection,  and  yet  the 
posterior  and  anterior  roots  were  greatly  degenerated. 


SPINAL    ANALGESIA  481 

"It  would  be  unwarranted  to  apply  these  findings  too  strictly  to 
man,  as  no  grave  changes  have  been  found  as  yet  in  the  human  spinal 
cord.  At  most,  our  findings  would  show  that  repeated  injections  of 
stovain  might  be  injurious,  and  would  make  one  cautious  in  employ- 
ing several  injections  within  a  short  time  in  the  same  subject.  We 
do  not  know  whether  stovain  has  more  effect  on  the  nervous  system 
of  the  dog  than  on  that  of  man." 

The  investigation  shows  further  that  the  paralysis  produced  by 
stovain  is  of  the  motor  type,  as  the  anterior  roots  were  greatly  de- 
generated. 

OCULAR  PALSIES 

Associated  with  the  nervous  lesions  following  analgesia  are  those  of 
the  ocular  muscles .  These  lesions  are  usually  transient,  appearing  five 
to  ten  days  after  puncture  and  disappearing  after  four  to  six  weeks. 
Occasionally  the  lesions  are  more  persistent  and,  in  rare  instances, 
have  been  permanent.  They  occur  much  more  frequently  in  high 
analgesia.  Their  frequency  has  been  stated  to  be  i  to  400  or  500 
cases.  Our  colleague,  Dr.  Delaup,  who  employs  almost  exclusively 
the  low  puncture,  has  had  1500  cases  and  his  associates  about  500 
more.  They  have  not  met  with  a  single  case  of  ocular  paralysis.  In 
the  experience  of  the  author  and  his  associates  no  such  cases  have 
been  observed. 

The  pathogenesis  of  these  palsies  is  not  at  all  clear.  They  have 
occurred  most  frequently  following  the  use  of  stovain,  but  also  happen 
with  the  other  agents.  The  irritating  qualities  of  stovain  and  its 
action  on  motor  nerves  is  well  recognized,  but  many  of  the  other 
agents  are  supposed  to  be  free  from  such  action.  One  theory  is  that 
the  irritation  is  due  to  changes  in  the  pressure  of  the  cerebrospinal 
fluid,  permitting  pressure  or  traction  on  the  nerves  as  they  course 
along  the  undersurface  of  the  brain.  This,  however,  is  very  unlikely, 
as  it  would  occur  just  as  frequently  with  low  puncture,  and  also  with 
operations  upon  the  spinal  cord,  when  frequently  large  quantities 
of  cerebrospinal  fluid  escape.  The  fact  that  occasionally  palsies 
have  followed  cerebral  operations  has  no  analogous  bearing  here,  for 
in  such  cases  the  disturbance  was  most  likely  due  to  edema  or  con- 
gestion following  the  procedure. 

The  possibility  of  hemorrhage  being  the  cause  has  been  advanced, 
but  has  not  met  with  much  support.  It  was  suggested  that  the 
change  in  the  cerebrospinal  pressure  acting  upon  diseased  vessels  in- 
duced minute  ruptures,  but,  if  such  were  the  case,  we  would  most 
likely  have  associated  disturbances  elsewhere  with  greater  frequency 
than  they  occur. 
31 


482 


LOCAL   ANESTHESIA 


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SPINAL   ANALGESIA  483 

The  fact  that  these  disturbances  occur  most  often  in  high  punc- 
tures would  suggest  the  direct  action  of  the  agents  or  toxic  properties 
induced  by  these  preparations  acting  directly  upon  the  nerves,  or  their 
origin  in  the  floor  of  the  fourth  ventricle;  to  act  on  the  nerve- trunks 
themselves  would  necessitate  a  much  higher  ascent  of  the  drug  and 
most  probably  produce  other  disturbances.  A  special  affinity  or  sus- 
ceptibility of  these  nerves  or  their  centers  must  also  be  presumed. 
This  last  view  is  concurred  in  by  Dr.  Babock  in  a  letter  to  Dr.  Reber, 
extracts  from  which  I  give  below. 

''There  have  now  been  given  by  Dr.  Steele,  Dr.  Martin  (and  his 
assistants),  Dr.  Applegate,  and  myself  about  2000  injections  for  the 
production  of  spinal  analgesia.  Personally,  I  have  given  about  1400 
injections,  having  used  stovain,  tropacocain,  eucain,  cocain  lactate, 
novocain,  and  alypin.  Most  of  the  injections  have  been  given  with 
stovain  or  tropacocain.  These  analgesics  have  been  given  dissolved 
in  water,  with  or  without  the  addition  of  sodium  chlorid,  adrenalin, 
10  per  cent,  alcohol,  or  strychnin.  I  have  had  great  difficulty  in  se- 
curing uniform  solutions,  although  ampules  of  the  solution  have  been 
prepared  for  us  by  German,  French,  and  several  American  chemists, 
and  we  have  also  prepared  the  solutions  extemporaneously.  All 
these  local  anesthetics  seem  to  share  with  cocain,  though  perhaps 
to  a  lesser  degree,  instability  in  the  presence  of  heat,  so  that  boiling 
may  set  free  certain  undesirable  and  even  toxic  substances.  I  have 
noticed  the  clinical  evidence  of  this  with  cocain  in  decreased  anesthetic 
action  and  severe  pain  after  the  injections  of  boiled  solutions  of 
this  alkaloid  for  purposes  of  ordinary  local  anesthesia.  I  have  seen 
local  necrosis  follow  the  injection  of  stovain  in  strong  solution  in  the 
prepuce.  When  used  for  spinal  analgesia,  boiled  stovain  solutions 
give  more  frequent  and  more  severe  secondary  headaches  (and,  at 
times,  even  stiffness  and  rigidity  of  the  muscles  of  the  back  of  the 
neck)  than  solutions  which  have  not  been  exposed  to  high  degrees 
of  heat.  Moreover,  the  solutions  which  show  the  greatest  untoward 
after-effects  seem  to  show  a  deficiency  in  analgesic  power.  Similar 
observations  have  been  made  in  reference  to  tropacocain. 

"The  interesting  fact  is  that  all  of  the  4  cases  in  which  ocular 
palsies  have  been  noticed  have  occurred  after  injections  for  analgesia 
of  the  lower  abdominal  segments. 

"At  the  present  time  I  would  draw  the  following  conclusions: 

"  i.  We  have  no  positive  final  proof  that  pure  stovain  or  tropaco- 
cain when  used  for  spinal  analgesia  will  be  followed  by  paralysis  of  the 
ocular  muscles. 


484  LOCAL    ANESTHESIA 

"2.  The  use  of  solutions  of  both  stovain  and  tropacocain  may  be 
followed  by  such  palsies  and  by  other  symptoms  suggesting  the 
presence  of  associated  by-products. 

"3.  The  palsy  may  occur  irrespective  of  the  use  of  adrenalin, 
alcohol,  glucose,  or  other  admixture,  although  it  is  possible  that  some 
of  these  substances  may  accentuate  or  favor  the  undesirable  effect. 

"4.  The  antiseptic  properties  of  stovain  and  tropacocain,  and  the 
fact  that  in  quite  a  number  of  instances  I  have  withdrawn  cerebro- 
spinal  fluid  from  one  to  many  days  after  the  spinal  analgesia,  and 
have  never  found  the  slightest  turbidity  or  cellular  exudate  or  other 
indication  of  inflammatory  action,  inclines  me  to  the  belief  that  sepsis 
or  a  bacterial  irritation  is  not  responsible  for  the  ocular  palsy. 

"5.  An  incidence  of  ocular  palsy  in  i  to  400  or  500  spinal  anal- 
gesias and  the  occurrence  of  frequent  headaches  should  make  sur- 
geons very  careful  to  avoid  heated  or  decomposed  solutions  for  spinal 
analgesias. 

"6.  Spinal  analgesia  should  not  be  discredited  by  the  untoward 
effects  resulting  from  decomposition  or  contaminating  by-products. 
Unfortunately,  no  Squibb  has  yet  arisen  to  do  for  spinal  analgesics 
what  has  been  done  for  ether  and  chloroform." 

THE  METHOD  OF  JONNESCO 

Dr.  Jonnesco  first  brought  forward  his  method  before  the  Inter- 
national Society  of  Surgery  in  Brussels,  Sept.,  1908,  when  he  reported 
14  cases.  Since  then  he  has  repeatedly  been  in  print,  either  alone  or 
with  Dr.  A.  Jiano,  writing  on  the  same  subject.  For  the  most  part, 
his  later  articles  have  been  in  defense  of  his  method  or  in  reply  to 
criticisms. 

The  essentials  of  his  injection  consist  of  high  punctures  over  the 
spinal  cord  proper,  and  in  the  addition  of  strychnin  sulphate,  which 
he  claims  combats  the  bad  effects.  He  writes  as  follows: 

"There  are  two  essential  points  of  novelty  in  this  method:  (i) 
The  puncture  is  made  at  a  line  of  the  spinal  column  appropriate  to 
the  region  to  be  operated  upon.  (2)  An  anesthetic  solution  is  used 
which,  thanks  to  the  addition  of  strychnin,  is  tolerated  by  the  high 
nervous  centers." 

He  at  first  advocated  four  points  of  puncture — a  mediocervical, 
upper  dorsal,  mediodorsal,  and  dorsolumbar — but  later  has  dropped 
two,  using  only  the  upper  dorsal,  between  the  first  and  second  dorsal 
vertebrae,  and  dorsolumbar,  between  the  twelfth  dorsal  and  first 
lumbar. 


SPINAL    ANALGESIA  485 

The  drug  used  has  been  principally  stovain.  The  strength  of  the 
dose,  as  well  as  the  dose  of  strychnin  used,  varies  with  the  point  of 
puncture  and  the  age  of  the  patient,  using  less  in  high  punctures  and 
in  young  subjects.  The  dose  of  strychnin  varies  between  0.5  to  i.o 
mg.  If  it  were  advisable  to  add  strychnin  it  could  be  given  before- 
hand, as  is  scopolamin  and  morphin.  Dr.  Fowler  has  recommended 
this,  giving  ^f0  gr-  strychnin  hypodermically  a  quarter  of  an  hour  be- 
fore the  puncture,  but  the  procedure  has  not  been  generally  adopted. 
In  administering  such  drugs  as  strychnin,  in  direct  contact  with 
the  nervous  system,  their  action  is  much  more  active  than  when  ad- 
ministered subcutaneously ;  but,  as  in  the  case  of  such  drugs  as  strych- 
nin, it  would  seem  unnecessary  to  inject  them  into  the  canal.  In 
spinal  puncture  our  aim  should  be  to  simplify,  as  much  as  possible, 
the  anesthetic  solution,  and  to  add  nothing  to  it  not  absolutely  neces- 
sary. Reports  from  surgeons  who  have  witnessed  Dr.  Jonnesco's 
injections  in  this  country  and  abroad  are,  on  the  whole,  condemna- 
tory of  the  method.  In  some  the  injections  worked  well,  in  others 
they  were  complete  or  partial  failures.  Many  were  made  quite  ill, 
and  some  barely  escaped  with  their  lives  after  heroic  efforts  at  resus- 
citation. The  method,  while  possible,  is  fraught  with  too  much 
danger,  and,  from  the  humane  standpoint,  unjustifiable. 

The  necessity  of  practising  artificial  respiration  on  conscious  but 
terrified  patients,  with  paralyzed  respiration,  must  be  an  experience 
they  can  never  forget. 

In  surgery  of  the  upper  parts  of  the  body,  when  general  anesthesia 
is  inadvisable,  local  or  regional  anesthesia  can  be  used  in  a  large 
number  of  cases,  and  this  number  is  steadily  increasing  with  our 
improvement  in  technic.  Where  high  spinal  anesthesia  seems  ad- 
visable the  method,  as  suggested  by  Barker,  would  seem  preferable, 
but  it  seems  doubtful,  even  with  this  method,  that  analgesia  will  be 
safe  higher  than  the  clavicles. 

TREATMENT  OF  AFTER-EFFECTS 

Slight  headache,  nausea,  or  temperature  usually  require  no  treat- 
ment, passing  off  in  a  few  hours  to  a  day  or  two  at  most.  The  head- 
ache may  be  very  severe,  often  unbearable,  and  may  persist  for  a 
week  or  longer.  The  usual  headache  remedies — ice-bag,  aspirin,  anti- 
pyrin,  phenacetin,  codein,  etc.' — may  be  used  and  sometimes  do  good. 
Nitroglycerin  and  amyl  nitrite  have  been  recommended  and  claimed 
to  benefit  some  cases,  though  it  would  seem,  on  theoretic  grounds, 
that  if  the  headache  is  due  to  reactionary  increase  in  intracranial 


486  LOCAL   ANESTHESIA 

tension  or  irritation  they  would  be  contra-indicated.  Small  doses  of 
atropin  hypodermically  have  also  been  said  to  yield  good  results. 
Several  observers  have  reported  benefit  following  tapping  of  the  sub- 
arachnoid  space,  allowing  the  escape  of  5,  10,  or  15  c.c.  of  cerebro- 
spinal  fluid,  which  in  these  cases  is  said  to  be  under  much  greater 
tension,  as  evidenced  by  the  way  the  fluid  will  flow  from  the  needle, 
and  is  often  turbid.  When  this  practice  has  been  followed,  the  head- 
ache has  been  much  benefited  or  entirely  disappears;  some  cases, 
where  the  fluid  has  been  turbid,  have  required  tapping  several  times. 
The  practice  should  be  tried  in  severe  cases  that  do  not  yield  to  other 
means. 

Temperature,  if  sufficiently  high  or  continuous,  should  be  com- 
bated by  the  usual  means — sponging,  wet  back,  or  ice-water  enemas. 

Nausea  or  vomiting  is  not  much  benefited  by  remedies  by  the 
mouth,  as  the  trouble  is  central,  but  these  may  be  tried,  and  some- 
times seem  to  do  good;  washing  the  stomach  may  also  be  tried. 

Keeping  the  patient  perfectly  quiet  in  bed,  free  from  surrounding 
disturbances  and  noises,  is  often  of  much  benefit  to  the  headache 
and  nausea;  any  movement  on  his  part  is  often  followed  by  an 
increase  in  the  headache  or  an  attack  of  nausea. 

The  after-vertigo  seems  to  yield  to  full  doses  of  strychnin  kept 
up  for  some  time,  but  it  is  often  persistent  and  may  last  for  several 
weeks. 

The  numerous  lesions  and  trophic  disturbances  should  be  treated 
the  same  as  those  arising  from  other  causes. 

In  the  event  of  spinal  meningitis  developing  as  the  result  of  a 
lumbar  puncture,  it  has  been  suggested  to  irrigate  the  subarachnoid 
space  by  two  punctures,  one  above  the  other  below  the  area  involved. 

It  is,  however,  not  very  likely  that  such  a  practice  will  do  any 
material  good  in  a  septic  inflammation  of  the  meninges.  The  irri- 
gation would  no  doubt  have  to  be  of  limited  duration  and  practised 
only  at  intervals.  However,  it  is  worth  bearing  the  procedure  in 
mind,  as  it  may  prove  of  some -value  in  exceptional  cases,  although 
the  procedure  itself  is  not  free  from  danger. 

EPIDURAL,  CAUDAL  OR  SACRAL  ANESTHESIA 

In  connection  with  spinal  and  paravertebral  anesthesia,  should 
be  considered  the  epidural  injections  of  Cathelin.  Cathelin  first 
conceived  the  idea  of  medicating  the  pelvic  nerves  in  the  sacral 
canal  for  the  relief  of  various  pelvic  neuroses,  especially  neuralgia 
of  the  lower  half  of  the  trunk,  incontinence  of  urine  and  sexual 


SPINAL   ANALGESIA 


487 


neuroses.  He  later  tried  the  method  for  the  purpose  of  inducing 
anesthesia,  but  met  with  little  success. 

The  technic  of  Cathelin's  injections  were  practically  the  same 
as  those  employed  to-day  for  surgical  purposes.  The  solutions  which 
he  used  were  either  plain  water  or  salt  solution  alone,  or  containing 
an  appropriate  quantity  of  cocain,  novocain,  codein  or  morphin, 
6  or  8  ounces  or  more  were  injected.  The  method  of  its  action  is 
hard  to  explain,  but  seems  to  be  due  to  the  physical  influence,  as 
well  as  such  chemical  changes  as  may  be  induced  by  bathing  the 
nerves  in  this  space  in  the  injected  solution. 

Cathelin  and  his  associates  reported  a  large  number  of  cases 
treated  by  this  method,  and  in  incontinence  of  urine  reported  49 
per  cent,  cured,  35  per  cent,  materially  improved  and  4  per  cent. 


2          Termination  of 
~~<i  'Spinal  Cora 


1  {__ — -Cauda  etjuina. 


T  Dural  sac 

terminally 

- .  Hiatus  sacral  is 
-Coccyx. 

Fig.   135- 

failures.  It  was  occasionally  necessary  to  repeat  the  injections 
several  times. 

The  method  had  been  used  in  a  desultory  way  from  time  to  time 
for  purposes  of  anesthesia.  Stoekel  met  with  somewhat  more  suc- 
cess in  this  direction,  but  it  was  not  until  Lawen's  paper  in  1910 
that  the  method  attracted  any  serious  attention. 

Anatomy. — The  dural  sac  ends  opposite  the  lower  border  of  the 
second  sacral  segment,  the  terminal  bundles  of  the  cauda  equina 
pass  through  the  dural  sac  (see  Fig.  135)  into  the  sacral  canal  on 


488  LOCAL     ANESTHESIA 

their  way  to  the  sacral  foramina  through  which  they  pass  to  form  the 
sacral  plexus  consisting  principally  of  the  sciatic,  vesical  and  pudic 
nerves.  The  sacral  canal  also  contains  the  sacral  plexus  of  veins 
and  much  loose  cellular  tissue  through  which  passes  the  filum 
terminalis  of  the  cord. 

The  lower  end  of  the  sacrum,  which  most  interests  us,  presents 
a  notch  or  triangle  due  to  the  lack  of  development  of  the  spinous 
processes,  on  the  lower  extremity  of  each  side  of  the  triangle  is  a 
bony  prominence  the  sacral  cornu,  which  articulates  with  the  coccyx. 

At  the  apex  of  this  triangle  is  found  the  sacral  hiatus,  a  bony 
canal,  which  opens  into  the  sacral  canal;  the  triangle  is  covered  with 
the  sacro-coccygeal  ligament  which  closes  the  sacral  hiatus.  The 
sacral  canal  is  flattened  from  before  backward  and  progressively 
diminishes  in  size  from  above  downward,  following  the  general  curve 
of  the  sacrum,  which  is  always  more  marked  in  the  male. 

The  hiatus  varies  much  in  size,  but  is  nearly  always  large  enough 
to  permit  the  ready  passage  of  the  needle. 

The  distance  from  the  sacral  hiatus  to  the  dural  sac  is  from  6  to 
9  cm. 

The  nerves  in  the  sacral  canal  are  identical  with  peripheral  nerves 
and  in  reaching  them  with  anesthetic  solutions  in  this  position  they 
are  affected  the  same  as  perineural  injections  made  around  nerve 
plexuses  in  other  parts.  The  method  is  essentially  different  from 
spinal  anesthesia,  in  which  the  injection  is  made  into  the  dural  sac 
and  is  confined  within  it,  being  distributed  by  the  spinal  fluid;  in 
sacral  injections  while  the  fluid  injected  may  ascend  the  vertebral 
canal  between  the  dura  and  vertebrae  for  a  considerable  distance,  it 
is  also  escaping  from  the  canal  in  all  directions  through  the  numerous 
foramina. 

(See  chapter  on  Paravertebral  Injections  for  the  movements  of 
fluid  in  the  vertebral  canal.) 

Another  essential  difference  is  that  in  spinal  injections,  but  a 
few  minims  of  solution  is  used  .containing  usually  less  than  i  gr.  of 
the  anesthetic  agent,  while  in  sacral  injections  30,  40  or  60  c.c.  of 
solution  may  be  used  containing  4  or  5  gr.  of  anesthetic. 

Solutions. — Lawen's  success  was  due  to  the  use  of  large  quanti- 
ties of  more  concentrated  solutions,  20  to  25  c.c.  of  1%  to  2  per  cent, 
solutions  of  novocain;  he  made  the  injection  in  the  sitting  position 
and  had  the  patient  remain  in  that  position  for  some  minutes  to 
retain  the  solution  at  the  lower  end  of  the  vertebral  canal.  He  was 
able  to  report  fairly  constant  results.  Gras  recommended  the  addi- 


SPINAL   ANALGESIA  489 

tion  of  the  sodium  bicarbonate,  which  he  states  permits  the  solu- 
tion to  more  readily  penetrate  the  nerve-sheaths.  Two  solutions 
were  used: 

Sodium  chloride o.io 

Sodium  bicarbonate o.  15 

Xovocain o .  60 

dissolved  in  30  c.c.  of  water.  Twenty  to  30  c.c.  of  this  solution,  which 
is  2  per  cent,  novocain,  are  injected;  or  a  slightly  larger  quantity 
of  the  following,  i^  per  cent,  novocain  may  be  used: 

Sodium  chloride 0.20 

Sodium  bicarbonate o.  20 

Xovocain 0.75 

dissolved  in  50  c.c.  of  water. 

The  solutions  are  first  boiled  for  a  few  seconds  just  before  use, 
which  converts  a  part  of  it  into  carbonate,  increasing  its  efficiency 
due  to  its  increased  hydrolytic  action.  After  cooling  5  to  10  drops 
of  a  i  :  1000  adrenalin  solution  is  added. 

Strauss  prepares  a  solution  by  the  addition  of  sodium  sulphate, 
which  he  claims  prevents  the  decomposition  of  adrenalin. 

Harris  who  has  had  much  experience  with  this  method,  claims 
that  the  efficiency  of  the  solution  is  increased  by  the  addition  of 
0.25  to  0.50  per  cent,  calcium  chlorid  to  a  i  p.er  cent,  novocain 
solution,  adding  about  10  drops  of  adrenalin  i  :  1000  before  injection; 
30  to  40  c.c.  are  used. 

While  the  author  has  used  these  various  salts  in  the  anesthetic 
solution  which  he  has  employed,  owing  to  the  inevitable  failure  of 
a  certain  number  of  all  cases  I  have  not  felt  certain  that  the  effi- 
ciency was  increased,  but  am  inclined  to  believe  that  the  calcium 
chlorid  solution  is  the  more  effective. 

If  any  additions  are  to  be  made  to  the  anesthetic  solution,  it 
would  seem  to  the  author  that  gelatin  has  some  claims  for  recogni- 
tion. Muroya  has  shown  (see  Paravertebral  Anesthesia)  in  experi- 
.  ments  on  rabbits  that  5  per  cent,  gelatin  in  the  solution  delays  its 
absorbtion  from  the  point  of  injection  and  thus  increases  its  effi- 
ciency. I  have  recently  been  using  this  in  my  injections,  but  am 
not  yet  prepared  to  make  a  positive  statement  as  to  its  advantages. 
Certainly  the  large  amount  of  cellular  tissue  in  the  sacral  canal  would 
seem  favorable  to  its  action.  The  free  space  in  the  sacral  canal  can 
at  most  not  exceed  a  few  drams  and  the  large  amount  of  solution 
injected  20,  30  and  40  c.c.  must  escape  up  the  vertebral  canal  and 
through  the  sacral  foramina  in  all  directions. 


49°  LOCAL   ANESTHESIA 

Hertzler  recommends  the  use  of  quinin  and  urea  using  from  60 
to  90  c.c.  of  a  0.6  per  cent,  solution.  I  have  had  no  experience  with 
this  agent  here  and  would  offer  the  same  objections  to  its  use  as 
enumerated  elsewhere. 

The  cause  of  occasional  failures  (10  to  15  per  cent.)  is  explained 
by  the  difficulty  of  having  anesthetic  solutions  when  injected  peri- 
neurally,  penetrate  effectively  all  parts  of  the  nerve- trunks.  Sacral 
anesthesia  is  essentially  perineural  anesthesia.  About  the  same 
percentage  of  failures  is  noted  in  all  perineural  injections  where  the 
nerves  are  of  any  size  as  in  KulenkampfFs  injection  of  the  brachial 
plexus.  The  same  may  be  more  readily  observed  when  injecting  the 
ulna  nerve  at  the  elbow,  unless  the  needle  be  made  to  penetrate  the 
nerve  the  anesthesia  is  uncertain.  The  delay  necessary  to  produce 
anesthesia  (twenty  to  thirty  minutes)  is  similarly  explained. 

Any  method  of  anesthesia  that  shows  10  per  cent,  failures  can- 
not become  universally  popular,  but  if  some  means  can  be  determined 
to  make  it  practically  a  certainty,  the  method  will  undoubtedly  gain 
great  popularity. 

It  is  possible  in  considering  the  above  that  the  use  of  much  smaller 
but  more  concentrated  quantities  of  solution  containing  5  per  cent, 
gelatin,  which  the  author  is  now  using,  may  improve  these  results. 

In  clinical  experience  so  far  slightly  better  results  have  followed 
the  use  of  larger  quantities  of  weaker  solutions  80  to  90  c.c.  of  0.5 
per  cent,  solutions,  the  pressure  effect  exerted  by  the  larger  quantity 
of  fluid  as  well  as  its  greater  diffusibility  has  favorably  influenced  the 
results,  although  there  still  remains  an  excess  of  10  per  cent,  failures. 

Technic. — The  patient  should  lie  on  either  side  near  the  edge  of 
the  table,  with  the  limbs  drawn  up.  I  find  lying  on  the  right  side 
more  convenient. 

The  last  sacral  spine  is  palpated  with  the  left  hand;  immediately 
below  this  is  the  sacral  triangle  with  the  hiatus  at  its  apex  above. 
The  skin  and  subcutaneous  tissue  over  this  region  is  anesthetized 
with  a  small  syringe  and  fine  needle,  using  the  same  solution  intended 
for  the  injection.  The  large  syringe  and  long  needle  are  now  used, 
the  needle  entered  about  i  inch  below  the  last  sacral  spine  and 
advanced  upward  in  the  direction  of  the  sacral  canal  injecting  as  the 
needle  is  advanced  searching  for  the  sacral  hiatus.  This  is  usually 
located  without  much  difficulty  in  thin  subjects  by  gently  feeling  the 
way  with  the  point  of  the  needle.  In  very  stout  subjects  more 
difficulty  may  be  encountered,  and  when  difficult  to  locate,  I  find 
a  convenient  aid  in  placing  the  left  index-finger  in  the  rectum  out- 


SPINAL   ANALGESIA  4QI 

lining  the  coccyx  and  lower  end  of  the  sacrum.  With  the  finger  in 
this  position,  the  needle  can  more  easily  be  passed  up  over  the  base 
of  the  coccyx  and  sacrum,  seeking  the  opening.  When  found,  the 
needle  is  gently  pushed  up  for  a  distance  of  2  or  3  inches  injecting  as 
it  is  advanced.  When  well  within  the  canal,  the  needle  point  should 
convey  the  sensation  of  being  in  a  free  space.  Care  should  be  taken 
not  to  enter  any  veins  or  the  termination  of  the  dural  sac.  This 
last  is  unlikely  at  this  depth,  but  both  should  be  insured  against  by 
gentle  aspiration  before  making  the  injection,  and  if  found  to  have 
entered  either  a  vein  or  the  dural  sac,  the  needle  should  be  slightly 
withdrawn  and  redirected  at  a  different  angle.  When  freely  within 
the  sacral  canal  as  the  needle  is  being  advanced,  it  is  advisable  to 
depress  the  syringe  slightly  forward,  thus  directing  the  point  of  the 
needle  toward  the  back  of  the  sacral  canal  to  avoid  wounding  the 
nerves  which  lie  more  in  front. 

Lawen  prefers  to  make  the  injection  with  the  patient  in  a  sitting 
position  with  the  back  near  the  side  of  the  table,  in  much  the  same 
position  as  is  used  for  spinal  puncture.  The  sacral  triangle  is  out- 
lined and  an  imaginary  line  drawn  from  its  apex  to  base  and  the 
needle  entered  at  the  middle  of  this  line,  advancing  it  upward  in  the 
recognized  direction.  These  landmarks  are,  however,  not  easily 
located  in  stout  individuals  and  the  position  is  not  a  convenient  one. 
I  much  prefer  to  use  the  technic  as  outlined  above.  When  well 
within  the  canal,  the  solution  should  be  slowly  injected;  detaching 
the  syringe  from  the  needle  for  refilling  as  occasion  requires.  While 
making  the  injections,  the  patient  will  occasionally  complain  of 
pains  in  the  legs,  which  are  transient  and  should  cause  no  concern. 
If  this  or  other  complaints  are  made,  the  injection  should  be  given 
more  slowly  or  stopped  for  a  few  minutes. 

Toxic  symptoms  when  they  occur  are  no  different  than  when 
using  the  same  agents  elsewhere.  Lawen  has  used  as  much  as  5  gr. 
of  novocain  here,  but  as  these  injections  should  be  regarded  as 
slightly  more  toxic  than  subcutaneous  infiltrations,  these  large 
doses  should  be  cautiously  used,  as  here  the  entire  quantity  is  thrown 
into  a  free  space  at  one  time  and  it  is  well  to  reserve  a  margin  of 
safety,  both  to  avoid  toxic  effects  and  in  the  event  of  failure  in  anes- 
thesia which  occurs  in  10  to  15  per  cent,  of  cases  to  permit  the  use 
of  direct  injections  into  the  field  of  operation  should  the  case  be 
suited  to  it. 

Having  made  the  injection,  the  patient  is  turned  on  his  back  to 
permit  the  uniform  distribution  of  the  anesthetic  to  both  sides  of 
the  sacral  canal;  otherwise  a  one-sided  anesthesia  may  result. 


492  LOCAL   ANESTHESIA 

The  field  can  now  be  prepared  while  waiting  for  the  anesthesia 
to  be  well  established,  which  takes  from  ten  to  twenty  minutes, 
though  at  times  slightly  longer. 

Extent  of  Anesthesia. — The  full  anesthetic  influence  is  exerted 
on  the  smaller  nerves  of  the  sacral  plexus  and  the  few  terminal 
filaments  which  make  up  the  coccygeal  plexus. 

The  great  sciatic  is  only  occasionally  affected  and  rarely  com- 
pletely anesthetized.  The  principal  nerves  most  constantly  anes- 
thetized are  the  pudic,  small  sciatic  with  its  inferior  pudendal  branch, 
the  vesical  nerve  and  other  small  branches.  This  group  of  nerves 
gives  us  anesthesia  of  the  lower  part  of  the  rectum,  perineum,  vaginal 
floor,  posterior  half  of  the  coverings  of  the  external  genitalia,  the 
bladder,  prostate  penis  and  clitoris;  the  anterior  scrotal  skin,  scrotal 
contents  and  anterior  portion  of  the  vulva  in  the  female  are  not 
anesthetized,  as  the  nerve  supply  is  from  the  ilio-inguinal  and  genito- 
crural.  The  upper  part  of  the  vagina  and  uterus  usually  escape  the 
anesthesia,  as  their  nerve-supply  is  partly  from  the  lower  lumbar 
region.  At  times  with  a  higher  ascent  of  the  anesthetic  along  the 
vertebral  canal,  some  of  the  parts  usually  exempt  are  brought -under 
its  influence.  This  ascent  of  anesthesia  may  be  favorably  influenced 
by  using  the  Trendelenburg  position,  in  which  the  anesthesia  may 
ascend  as  high  as  the  umbilicus,  but  when  this  is  done,  the  degree  of 
anesthesia  is  less  certain. 

The  order  in  which  the  anesthesia  usually  manifests  itself  is, 
first  in  the  parts  supplied  by  the  coccygeal  plexus,  then  the  anus  and 
anal  canal,  perineum  and  lastly  the  penis  or  clitoris,  and  disappears 
in  the  reverse  order,  the  coccyx  the  last  to  feel  pain. 

The  duration  of  anesthesia  varies  within  wide  limits.  When  a 
good  surgical  anesthesia  has  been  secured,  the  minimum  time  is 
usually  forty-five  minutes,  and  it  may  last  as  long  as  two  hours. 

As  is  common  with  all  local  and  regional  methods,  complete 
muscular  relaxation  is  noted  in  the  parts  affected  due  to  the  absence 
of  all  reflexes  as  well  as  to  a  certain  amount  of  motor  paralysis.  This 
is  a  decided  advantage  and  permits  the  more  ready  handling  and 
retraction  of  the  parts.  The  complete  muscular  relaxation  in  addi- 
tion to  the  anesthesia,  has  prompted  its  use  in  labor,  particularly 
in  old  primipara,  where  it  is  often  used  to  great  advantage  if  properly 
timed  to  meet  the  head  at  the  perineum.  For  this  purpose  it  is 
usually  given  when  the  head  is  well  engaged  in  the  pelvis.  It  does 
not  seem  to  affect  the  progress  or  intensity  of  the  pains. 

Surgical  Applications. — In  addition  to  the  original  therapeutic 


SPINAL   ANALGESIA  493 

uses  as  suggested  by  Cathelin  and  its  employment  in  labor,  it  finds 
a  ready  field  of  usefulness  in  many  surgical  procedures.  All  opera- 
tions in  the  ischio-rectal  region  and  lower  end  of  the  rectum,  includ- 
ing its  resection,  perineorrhaphy,  internal  and  external  urethrotomy 
and  all  operations  upon  the  penis,  passage  of  sounds,  cystoscopy 
and  all  intravesical  operations,  such  as  the  destruction  of  growths 
by  electricity,  perineal  prostatectomy  and  suprapubic  prostatectomy 
when  combined  with  infiltration  for  the  suprapubic  incision. 

Complications  and  After-effects. — These  are  few  and  as  a  rule 
of  no  serious  concern,  aside  from  possible  infection,  which  should  be 
regarded  as  due  to  improper  technic.  The  only  serious  consequences 
can  result  from  the  use  of  a  toxic  quantity  of  the  anesthetic.  Motor 
paralysis  which  sometimes  may  occur,  possesses  no  disadvantage, 
except  in  such  cases  as  cystoscopy,  etc.,  where  the  patient  may  be 
forced  to  remain  recumbent  for  an  hour  or  more. 

While  this  method  is  still  in  its  infancy,  it  has  already  gained  a 
wide  range  of  popularity  and  as  it  possesses  none  of  the  disadvantages 
or  dangers  of  spinal  anesthesia,  it  will  probably  be  developed  to  a 
high  state  of  efficiency.  The  injection  is,  however,  not  made  with  the 
same  ease  or  certainty  as  spinal  puncture,  but  requires  some  little 
practice.  The  element  of  uncertainty,  10  to  15  per  cent,  failures, 
and  delay  before  anesthesia,  ten  to  thirty  minutes,  operates  con- 
siderably against  its  universal  adoption.  Further  experience  will 
no  doubt  largely  eliminate  these  objections.  As  used  at  present,  the 
best  results  are  obtained  by  the  use  of  large  quantities  of  weak 
solution  40  to  50  c.c.  of  0.5  per  cent,  novocain  injected  high  in  the 
canal. 


CHAPTER  XXI 

PARAVERTEBRAL  AND  PARASACRAL  ANESTHESIA 
PARAVERTEBRAL  ANESTHESIA 

THE  introduction  of  paravertebral  anesthesia  is  quite  a  new  de- 
parture among  regional  methods,  and  while  even  now  beyond  the 
experimental  stage,  having  been  used  successfully  by  a  number  of 
operators,  the  method  has  not  been  sufficiently  developed  yet  as  a 
routine  procedure,  but  when  perfected  may  promise  much  for  the 
future. 

Undoubtedly  the  first  attempt  at  a  paravertebral  injection  was 
by  Corning  in  1885,  who  attempted  to  inject  an  anesthetic  solution 
in  close  contact  with  the  spinal  cord  by  making  a  deep  injection  near 
the  vertebrae,  these  experiments  were  the  beginning  of  spinal  anes- 
thesia. It  is  possible  that  he  got  within  the  membranes,  though  he 
did  not  intend  to. 

The  paravertebral  methods  of  to-day  were  first  conceived  by 
Sellheim,  who  in  1905  anesthetized  the  abdominal  walls  by  an  injec- 
tion made  around  the  roots  of  the  eighth  to  twelfth  dorsal,  iliohypo- 
gastric,  and  ilio-inguinal  nerves. 

The  roots  of  the  spinal  nerves  join  within  the  intervertebral  for- 
amina, and  immediately  divide  into  anterior  and  posterior  branches; 
from  the  anterior  branch  a  filament  is  given  off,  which  runs  forward  to 
communicate  with  the  sympathetic  system. 

In  making  these  paravertebral  injections  the  object  is  to  reach  the 
nerves  at  their  point  of  division,  so  as  to  anesthetize  this  communi- 
cating filament  (Fig.  137). 

From  a  study  of  the  vertebral  column  of  the  average  adult,  with 
a  view  of  obtaining  information  for  the  guidance  of  paravertebral 
injections,  we  find  on  its  posterior  aspect  that  if  a  vertical  line  is 
drawn  down  the  tips  of  the  spinous  processes  and  lateral  measure- 
ments made  from  this  line  the  free  interval  between  the  transverse 
processes  is  about  i  inch  on  each  side  (Fig.  137).  While  the  con- 
formation of  the  vertebrae  in  the  dorsal  and  lumbar  regions  is  quite 
different,  this  measurement  holds  good  along  the  entire  dorsal  and 
lumbar  regions.  As  the  intervertebral  foramina  are  shielded  pos- 

494 


D. 

MOTOR 
DISTRIBUTION. 


8UPRASPINATU8. 
'NFRA8PINATU8 
TERES  MINOR.  I 

BICEPS.  BRACHIALIS. 
DELTOID.  BRACHIO- 
RADIALI8.  SUPINATOR 
SU83CAP.  PRONATOR8. 


EXTENSORS  OF  WRIST. 
FLEXORS  OF  THE  WRI8 


INTERCOSTAL 
MUSCLES. 


SARTORtUS,  ADDUCTORS 


FXTENSORS  OF  KNEE  A 


CALF  MUSCLES.GLUTE 
PERONEI.  ANTERIOR 
GROUP  OF  LEO  MUS- 

[CLES.  INTRINSIC  MU8C- 
ES  OF  FOOT. 


CCEL.  URIN.iC. 
LADDER  AND  RECTUM. 


E.       F. 

SENSORY   REFLEXES. 
AREAS. 


^  NECK  AND  SCALP 


NECK  AND 
SHOULDER. 


JENSIFORM  AREA. 


ABDOMEN. 
UMBILICUS  (I 


ANTERIOR  ASPECT  OF 
iH  BELOW  SECOND 
LUMBAR  ROOT. 


NARROW  STRIP  ON 
BACK  OF  THIGH,  LEG 
>*NO  ANKLE;  SOLE; 
PART  OF  OORSUM  OF 

FOOT. 


>REA  OF  BACK  OF  THIGH. 


FOOT  OLONU>. 


Fig.   136. — Topography  and  distribution  of   the  spinal  nerve-roots.     (Gerrish,   "A 

Text-book  of  Anatomy.") 


496 


LOCAL   ANESTHESIA 


teriorly  by  the  lateral  projections  of  the  articular  processes,  a  point 
of  about  Y±  inch  further  out,  making  i34  inches  from  the  midline, 
is  best  selected  as  the  point  of  puncture,  so  as  to  enable  the  needle 
to  be  directed  upward  and  inward  toward  the  in tervertebral  foramina. 

The  average  interval  between  the  transverse  processes  in  the  dor- 
sal region  is  about  ^  inch,  while  the  midpoint  of  this  space  lies  in  a 
vertical  line  about  i  inch  from  the  midpoint  of  the  space  above  or 
below  it. 

In  the  lumbar  region  the  free  space  between  the  transverse  proc- 
esses is  from  ^  to  %  inch,  and  the  distance  from  the  midpoint  of 
one  space  to  that  of  the  other  is  about  \Y±  inches. 

On  the  lateral  aspect  we  find  that  measurements  made  directly 


Fig.  137. — Posterior  view  of  dorsal  and  lumbar  spinal  column  with  measurements  for 
paravertebral  injections.     (See  text.) 

inward,  from  a  plane  passing  through  the  tips  of  the  spinous  processes, 
reach  the  intervertebral  foramina  at  a  distance  of  about  1%  inches 
in  the  upper  dorsal  to  about  i^  inches  in  the  lower  dorsal  and  lum- 
bar regions.  To  this  distance  we  should  add  Y±  inch  or  more  for 
soft  parts,  according  to  the  stoutness  of  the  individual  (Fig.  138). 
It  is  further  seen  on  the  lateral  view  that  the  tips  of  the  spinous  proc- 
esses in  the  dorsal  region  considerably  overlap  the  vertebra  below, 
this  downward  projection  growing  less  in  the  lower  region,  so  that 
no  reliable  guide  is  offered  by  these  processes  for  the  location  of  the 
space  between  the  transverse  processes;  while  in  the  lumbar  region 
it  may  be  fairly  accurately  stated  that  the  lower  border  of  any 
transverse  process  lies  slightly  below  the  level  of  the  tip  of  the  spin- 


PARAVERTEBRAL  AND  PARASACRAL  ANESTHESIA       497 

ous  process  of  the  same  vertebra,  and  that  a  needle  directed  inward 
and  upward  at  the  proper  lateral  position  (i}£  inches  from  the  mid- 
line)  and  about  on  a  level  with  the  middle  of  the  spinous  process 
should  pass  freely  between  the  transverse  processes  of  that  vertebra 
and  the  one  above. 

In  the  dorsal  region,  as  we  have  no  such  guide,  it  is  best  to  feel 


Fig.  138. — Lateral  view  of  dorsal  and  lumbar  spinal  column  with  measurements.     (See 

test.) 

for  the  intertransverse  space,  with  the  point  of  the  needle  directed 
inward  from  a  line  i  Y±  inches  lateral  from  the  tips  of  the  spinous  proc- 
esses, and,  having  located  this  interval  at  any  one  point,  the  point 
of  puncture  for  the  space  above  or  below  will  be  about  i  inch  re- 
moved on  the  lateral  line. 

These  measurements  were  made  on  the  vertebral  columns  of 
several  adult  skeletons  and  utilized  for  verification  on  the  cadaver, 


4Q8  LOCAL   ANESTHESIA 

and,  while  subject  to  small  variations,  will,  I  believe,  be  found  fairly 
accurate  for  the  adult  of  average  size. 

La  wen,  in  1911,  performed  a  nephrotomy  by  blocking  the  inter- 
costal and  three  upper  lumbar  nerves. 

The  most  noteworthy  articles  upon  this  subject  to  date  have 
been  by  La  wen,  Kappis,  Heile,  Wilms,  and  Franke;  but  Finsterer's 
work  on  this  subject  has  been  particularly  thorough  and 
comprehensive. 

One  and  1.5  per  cent,  solutions  of  novocain  with  adrenalin  have 
been  the  strength  usually  employed.  The  total  quantity  of  novo- 
cain used  being  0.4  to  0.8  gm.  Finsterer,  in  a  case  in  which  he  used 
0.4  gm.,  injecting  the  eleventh  and  twelfth  dorsal  and  first  and  second 
lumbar  nerves,  reports  that  the  duration  of  the  anesthesia  was  two 
hours. 

In  extensive  operations,  where  six  or  eight  points  are  injected  on 
each  side,  using  approximately  5  c.c.  at  each  point,  which,  com- 
bined with  the  skin  injections  at  the  puncture  points,  brings  the 
total  quantity  of  solution  used  up  to  75  to  100  c.c.,  which,  if  it  be  a 
i  per  cent,  solution,  certainly  would  appear  to  exceed  the  safe  limits 
of  the  drug. 

While  no  mishaps  have  occurred,  some  patients  have  shown 
symptoms  which  have  served  as  a  warning  note;  this  has  stimulated 
animal  experimentation  to  determine  the  best  method  of  procedure. 
As  some  of  the  injected  solution  must  reach  the  epidural  space 
through  the  spinal  foramina,  rather  free  epidural  sacral  injections 
were  made  upon  animals  to  study  the  movements  of  a  definite 
quantity  of  solution  injected  within  the  epidural  space. 

Lawen  and  Gaza  found  with  colored  solutions  plus  adrenalin  in 
epidural  sacral  injections  that  the  solution  often  ascended  as  far  as 
the  lower  portion  of  the  thoracic  cord,  while  Muroya,  in  a  somewhat 
similarly  made  injection,  found  that  the  ascent  of  the  fluid  was  often 
higher— to  the  cervical  region  and  frequently  into  the  skull. 

The  difference  in  the  results  obtained  by  these  investigations 
may  be  accounted  for,  as  Muroya  states,  by  the  quantity  of  the  solu- 
tion used  and  the  pressure  under  which  the  injections  are  made. 
He,  accordingly,  timed  the  rapidity  of  his  injections  and  used  10  c.c. 
per  kilogram  of  body-weight  of  the  rabbit,  of  a  colored  5  per  cent, 
novocain  adrenalin  solution,  injecting  i  c.c.  per  minute,  and  found, 
as  in  his  previous  experiments,  that  the  solution  ascended  often  as 
high  as  the  skull,  and  but  seldom  was  found  to  stop  at  the  middorsal 
region. 


PARAVERTEBRAL  AND  PARASACRAL  ANESTHESIA       499 

Muroya  found  that  in  rabbits  paravertebral  injections  are  rela- 
tively more  toxic  than  subcutaneous;  this  may  be  explained  in 
several  ways:  (i)  The  solution  may  ascend  to  the  higher  centers 
through  the  subdural  space,  or  (2)  the  blood-vessels  may  more 
rapidly  absorb  it  in  this  position;  (3)  it  may  be  rapidly  taken  up  by 
the  large  network  of  lymph-spaces  which  overlie  the  vertebral 
column,  particularly  in  the  abdominal  cavity,  as  the  colored  solution 
has  often  been  found  in  animals  high  up  in  the  thoracic  duct  a  few 
minutes  after  injection.  This  absorption  through  the  lymph-spaces 
seems  the  most  probable. 

A  comparison  made  by  Muroya  with  subcutaneous  and  paraver- 
tebral injections  of  novocain  colored  with  methylene-blue  showed 
methylene-blue  in  the  urine  in  ten  to  twenty  minutes  following  sub- 
cutaneous injections,  and  in  five  to  ten  minutes  following  para- 
vertebral. 

From  the  work  of  Muroya  upon  rabbits,  he  concluded  that  the 
paravertebral  injection  is  six  times  more  toxic  than  the  subcuta- 
neous, but  that  this  toxicity  can  be  greatly  reduced,  making  it  about 
equal  to  the  subcutaneous  injection,  by  combining  5  per  cent,  gelatin 
with  the  adrenalin  in  normal  salt  solution,  the  adrenalin  preventing 
or  delaying  its  absorption  through  the  blood-vessels,  while  the 
gelatin  delays  its  diffusion  into  the  cellular  lymph-spaces. 

By  the  use  of  this  mixture  its  action  at  the  point  of  injection  is 
intensified,  as  the  solution  is  more  or  less  retained  at  the  point  of  in- 
jection. 

In  drawing  positive  conclusions  from  the  above  it  must  be  re- 
membered that  it  is  not  always  safe  to  apply  the  results  of  animal 
experimentation  to  man.  In  the  first  place  the  formation  of  the 
sacral  canal  may  not  exactly  correspond  to  that  of  man,  where  the 
numerous  large  foramina  for  the  exit  of  nerve-trunks  permit  any 
injected  solution  to  readily  escape  in  all  directions,  and  besides  the 
difference  in  the  distance  between  the  sacrum  and  skull  in  the  rabbit 
and  in  man  is  considerable.  These  experiments  are,  however,  more 
valuable  for  determining  the  movements  of  the  injected  fluid  in 
epidural  (sacral)  injections. 

Kappis  has  reported  paravertebral  injections  of  the  cervical 
region.  A  line  on  either  side  of  the  spinous  processes  was  anes- 
thetized, and  a  long  needle  advanced  forward  until  the  transverse 
process  was  encountered.  The  interval  between  these  processes 
is  sought  for  by  the  point  of  the  needle,  which  is  advanced  from  i 
to  i%  cm.  further  and  the  injection  made. 


500 


LOCAL    ANESTHESIA 


Kappis  used  1.5  per  cent,  novocain-suprarenin  solution.  The 
performance  of  paravertebral  injections  in  such  regions  as  the  neck 
must  receive  further  experimental  study  before  it  can  be  popularized ; 
the  likelihood  of  the  solution  reaching  the  phrenic  nerve  in  effective 
quantity  should  not  be  lost  sight  of;  its  origin  from  the  third,  fourth, 
and  fifth  cervical  is  practically  the  center  of  the  field,  and  after  forma- 
tion its  course  is  more  superficial.  If  the  solution  is  effectively  used 
this  nerve  should  be  paralyzed  \  however,  unless  the  procedure  is  car- 
ried out  on  both  sides,  the  temporary  one-sided  paralysis  is  not 
likely  to  be  of  consequence. 


Fig.  139. — a  and  b,  points  of  injection  on  line  drawn  over  transverse  processes  of  cervical 
vertebrae.     (From  Braun.) 

The  paravertebral  injection  of  the  cervical  region  is  carried  out 
by  Braun  in  a  somewhat  different  way,  following  the  suggestion  of 
Heidenhain. 

The  injections  are  made  from  the  side,  between  the  third  and 
fifth  vertebrae,  rather  freely  with  a  0.50  per  cent,  novocain-adrenalin 
solution  at  the  point  where  the  nerves  lie  rather  close  together.  A 
line  is  drawn  on  the  neck  from  the  transverse  process  of  the  atlas 
which  is  felt  under  the  point  of  the  mastoid  process  downward  over 
the  transverse  process  of  the  sixth  cervical  vertebra  (tuberculum 
carotidum). 


PAEAVERTEBRAL  AND  PARASACRAL  ANESTHESIA 


501 


This  line  represents  the  point  at  which  the  long  axis  of  the  trans- 
verse processes  reach  the  surface,  and  forms  a  sharp  angle  with  the 
edge  of  the  sternomastoid  as  it  gradually  draws  away  from  this 
muscle  (Fig.  139). 

Two  points  of  puncture  are  made  on  this  line — the  upper  one 
on  a  level  with  the  lower  border  of  the  inferior  maxilla,  the  lower  one 
on  a  level  with  the  promontory  of  the  larynx. 

From  these  two  points  of  puncture  the  needle  is  carried  directly 
inward,  until  it  comes  into  contact  with  the  transverse  processes  of 


Fig.  140.  Fig.  141. 

Figs.  140,  141. — Points  of  injection  for  paravertebral  anesthesia  for  kidney  operations, 
showing  area  of  resulting  anesthesia.     (From  Braun.) 

the  vertebra,  injecting  freely  in  the  interval  between  the  two  points 
of  puncture  by  injections  made  deep  down,  in  a  fan-like  manner, 
using  in  all  about  30  to  40  c.c.  of  a  0.50  per  cent,  novocain-adrenalin 
solution.  The  great  vessels  of  the  neck  are  in  no  danger,  as  they  lie 
somewhat  in  front  of  this  line. 

For  operations  on  the  midline  of  the  neck  both  sides  are  injected, 
and  where  it  involves  the  larynx  the  superior  laryngeal  is  blocked  in 
addition,  as  described  in  the  chapter  on  the  neck,  and  if  the  field  of 
operation  extend  to  the  base  of  the  lower  jaw  the  third  division  of 
the  fifth  nerve  is  also  blocked. 


502  LOCAL   ANESTHESIA 

Braun  states  that  this  method  produces  an  effective  surgical 
anesthesia  for  all  major  operations  in  this  region. 

Braun  has  performed  three  nephrotomies  by  paravertebral 
methods,  and  made  accurate  observations  of  the  extent  of  the  field 
of  anesthesia. 

The  eighth  to  the  twelfth  dorsal  nerves  were  injected  each  with 
5  c.c.  of  a  i  per  cent,  solution;  the  line  of  puncture  lay  on  a  line  which 
corresponded  to  the  upward  extension  of  the  outer  margin  of  the 
quadratus  lumborum. 

A  point  of  anesthesia  was  now  established  over  the  crest  of  the 
ilium  at  the  outer  border  of  the  quadratus  lumborum;  between  this 
point  and  the  point  of  puncture  for  the  twelfth  dorsal  nerve  was  a 
rather  free  and  deep  injection  made  down  to  and  including  the 
fatty  tissue  around  the  kidney,  using  for  this  purpose  75  c.c.  of  a  0.50 
per  cent,  novocain-suprarenin  solution.  The  points  of  injection 
and  distribution  of  anesthesia  are  shown  in  Figs.  140  and  141. 

Braun  states  that  the  entire  procedure  was  painless,  including 
the  luxation  of  the  kidney,  and  while  his  patients  were  thin  he  be- 
lieves that  the  anesthesia  of  this  region  by  local  methods  has  been 
conquered. 

Finsterer,  who  has  employed  this  method  for  6  laparotomies  and 
other  major  operations,  gives  his  technic  as  follows: 

The  spine  of  the  first  lumbar  vetebra  is  located,  and  a  point  on 
the  skin  from  3  to  3^  cm.  laterally  is  anesthetized;  the  needle 
marked  in  centimeters  is  passed  vertically  inward  through  this  anes- 
thetized point  to  a  depth  of  from  4  to  5  cm.,  according  to  the  stout- 
ness of  the  individual,  until  the  transverse  process  is  struck;  the 
upper  border  of  the  process  is  then  felt  for  with  the  needle;  when  this 
point  is  reached  the  syringe  is  carried  outward  and  downward, 
directing  the  needle-point  upward  and  inward,  when  it  is  advanced 
about  3^  to  i  cm.  further,  and  5  c.c.  of  a  i  per  cent,  solution  of  novo- 
cain  adrenalin  is  then  injected  in  a  fan-shaped  area.  Care  should 
be  exercised  not  to  push  the  needle  too  deeply,  as  the  anesthetizing 
fluid  will  pass  beyond  the  ganglion  and  be  useless. 

The  points  for  reaching  the  first,  second,  and  third  lumbar  nerves 
will  be  at  intervals  of  3^  to  4  cm.  from  each  other,  according  to  the 
size  of  the  individual. 

PARASACRAL  ANESTHESIA 

The  anterior  surface  of  the  sacrum  shows  that  the  anterior  sacral 
foramina  lie  almost  always  in  a  straight  line,  which  from  below  up 
has  a  slightly  outward  angle.  The  distance  between  the  midpoints 


PARAVERTEBRAL  AND  PARASACRAL  ANESTHESIA 


503 


of  the  first  sacral  foramina  is  i%  inches,  and  between  the  midpoints 
of  the  fourth  is  i%  inches  (the  fifth  sacral  foramen  is  formed  by 
articulation  with  the  coccyx,  and  does  not  appear  as  a  separate 
opening),  so  that  if  a  line  is  drawn  down  the  midline  of  the  sacrum 
a  line  running  over  the  center  of  the  foramina  diverges  but  %  inch 
from  the  midline  in  passing  upward  from  the  fourth  to  the  first 
foramina. 

The  distance  from  the  free  margin  of  the  sacrum  at  its  lower  free 


i 


Fig.  142. — Anterior  view  of  sacrum,  slightly  reduced,  showing  relative  distances  to 

foramen. 

border  (sacrococcygeal  junction)  along  the  line  passing  over  the 
center  of  the  foramina  is  %  inch  to  the  midpoint  of  the  fourth 
foramen,  i^  inches  to  the  midpoint  of  the  third  foramen,  2%  inches 
to  the  midpoint  of  the  second  foramen,  and  3^  inches  to  the  mid- 
point of  the  first  sacral  foramen.  This  then  makes  the  foramina 
the  following  distances  apart:  approximately  %  inch  from  the  fourth 
to  the  third  and  from  the  third  to  the  second,  and  the  first  is  i  inch 
from  the  second  (Fig.  142). 

On  the  lateral  view  it  is  seen  that  if  the  needle  is  passed  straight 


5°4 


LOCAL   ANESTHESIA 


in  over  the  lower  free  margin  of  the  sacrum  %  inch  from  the  midline, 
and  directed  upward  almost  in  a  straight  line,  with  a  very  slight  out- 


Fig.  143. — Distances  and  relative  position  of  foramen  on  lateral  view- of  sacrum. 


Fig.  144. — Direction  of  long  needle  for  parasacral  injections.     (From  Braun.) 

ward  inclination,  that  it  will  pass  directly  over  the  fourth,  third,  and 
second  foramina,  when,  after  meeting  the  bone  above  this  opening, 


PARAVERTEBRAL  AND  PARASACRAL  ANESTHESIA 


505 


if  it  will  be  slightly  withdrawn  and  redirected,  with  the  point  elevated 
Y^  inch  and  advanced  i  inch  further,  that  it  will  reach  the  first  sacral 
foramina  (Figs.  143,  144). 

It  is  seen,  after  a  study  of  numerous  sacrums,  that  the  interme- 


laieral  sacral  artery 


lumbosacral  trunk 


inf.  mestnteric  artay_ 


sacr.  nerves  IV  and  V 


\\,;\ 

'Cottntus\       ««»«»/ iw-nw 
•  pudcndal  plexus 

•I  pudic  art.    X 
iddle  haemorrhoidal  art.  X 


Fig.  145. — The  blood-vessels  and  nerves  on  the  right  pelvic  wall.  The  pelvis  has 
been  halved  by  a  sagittal  section  and  the  genitalia  removed.  X  =  Branches  to  the 
coccygeus.  X  X  =  Branch  to  levator  ani.  +  =  Site  of  abdominal  inguinal  ring. 
+  -f-  =  Branches  to  pyrif ormis.  (Sobotta  and  McMurrich.) 

diate  foramina  between  the  fourth  and  first  in  some  few  are  placed 
somewhat  outside  of  the  straight  line,  passing  over  the  center  of  the 
openings;  this  lateral  variation  is  usually  about  %  inch,  and  was 
never  seen  to  exceed  Y±  inch. 


506  LOCAL    ANESTHESIA 

As  the  nerves,  as  they  emerge  from  the  foramina  run  downward, 
outward,  and  forward  (Fig.  145),  it  would  seem  best  to  slightly 
increase  the  lateral  angle  of  the  needle,  so  that  at  a  depth  of  about 
2  inches  its  point  will  be  about  Y±  inch  lateral  to  the  point  of  entrance; 
in  this  way  the  needle  cannot  go  astray,  and  may  even  transfix  these 
nerves  though  the  foramina  do  not  lie  in  a  straight  line. 

The  injections  are  made,  according  to  Braun,  as  follows:  With 
the  breech  of  the  patient  well  presented,  the  long  fine  needle  (for 
this  purpose  it  should  be  about  5  or  6  inches  long)  is  entered  about 
1^2  or  2  cm-  from  the  middle  line,  on  a  level  with  the  sacrococcygeal 
joint.  As  the  inner  surface  of  the  sacrum  up  to  about  the  second 
foramina  is  but  little  curved,  the  needle  is  advanced  straight  up  from 
the  point  of  puncture,  in  close  contact  with  the  bone,  until  it  im- 
pinges with  it  near  the  second  sacral  foramina;  this  point  is  about 
6  to  7  cm.  from  the  point  of  puncture  at  the  sacrococcygeal  joint  in 
the  adult,  not  counting  the  thickness  of  the  soft  parts. 

One  proceeds  in  the  following  manner:  The  needle  is  entered  on 
the  inner  surface  of  the  lower  border  of  the  sacrum  and  directed  up- 
ward in  a  parallel  direction  seeking  for  the  edge  of  the  bone;  the  needle 
is  then  pushed  along  the  inner  surface,  parallel  with  the  middle  line, 
until  it  reaches  the  bone  at  about  the  recognized  depth;  along  the 
entire  way,  from  the  second  to  the  fifth  sacral  foramina,  20  c.c.  of  i 
per  cent,  novocain-adrenalin  solution  is  injected.  The  injections 
should  not  be  made  except  when  the  needle  is  in  contact  with  the 
bone.  The  needle  is  now  drawn  back  to  the  edge  of  the  bone  and 
redirected  at  a  slightly  increased  angle,  but  still  parallel  to  the  middle 
line  toward  the  linea  innominata;  reaching  the  bone  just  above  the 
first  sacral  foramina,  about  9  or  10  cm.  from  the  point  of  entrance 
(not  including  the  soft  parts),  20  c.c.  of  the  i  per  cent,  solution  are 
injected  here. 

Before  finally  withdrawing  the  needle  5  c.c.  are  injected  between 
the  coccyx  and  rectum.  The  same  procedure  is  repeated  on  the  op- 
posite side,  using  in  all  about  100  c.c.  of  solution.  Braun  states  that 
there  is  no  danger  of  injuring  the  rectum  if  empty,  as  it  is  pushed  out 
of  the  way  by  the  advancing  needle,  but  a  finger  may  be  inserted 
within  it  if  preferred  for  guidance. 

This  method  produces  an  effective  means  of  anesthesia  for  such 
operations  as  prostatectomy,  prolapse  of  the  uterus,  and  resections 
of  the  rectum,  as  well  as  other  minor  operations  upon  these  parts, 
but  it  is  not  sufficient  for  a  total  hysterectomy,  as  here  the  upper 
part  of  the  field  is  not  reached  by  the  pelvic  nerves. 


CHAPTER  XXII 
THE  HEAD,  SCALP,  CRANIUM,  BRAIN,  AND  FACE 

THE  surgery  of  the  head  with  regional  methods  of  anesthesia  is 
one  of  the  most  attractive  and  fascinating  in  the  entire  body,  and  its 
operative  procedure  among  the  most  brilliant  in  the  entire  domain 
of  surgery.  In  itself  a  vast  field  for  the  application  of  intra-  and 
paraneural  methods,  presenting  an  intricate  labyrinth  of  foramina, 
canals,  fissures,  and  tracts  for  the  passage  of  the  great  nerve-trunks 
and  their  branches,  always  appearing  in  a  new  and  interesting  light, 
due  to  the  many  brilliant  minds  that  have  made  this  region  a  field 
of  study,  and  have  evolved  new  ways  and  means  of  access  and  ap- 
proach to  the  great  nerve-trunks  at  their  basal  foramina  and  even 
their  injection  within  the  skull. 

Those  who  study  the  skull  with  the  view  of  determining  the  most 
accurate  and  reliable  methods  of  reaching  by  deep  injections,  espe- 
cially the  branches  of  the  fifth  nerve  at  their  points  of  emergence  from 
the  various  foramina  or  even  within  them,  find  in  this  study  a 
wealth  of  information.  The  deeper  the  study  is  pursued  the  more 
absorbing  and  interesting  does  it  become.  The  skull  should  be 
constantly  before  us  and  the  foramina  viewed  from  every  possible 
angle  of  approach.  The  more  versatile  and  proficient  the  student 
becomes  in  this  study  the  more  successful  will  he  be  in  making  the 
deeper  and  more  difficult  injections.  The  foramen  ovale  and  fora- 
men rotundum  are  the  most  difficult  to  reach  and  this  difficulty  is 
only  overcome  by  constant  study  of  the  skull  and  practice  upon  the 
cadaver. 

In  this  vast  field  the  work  is  of  interest  alike  to  physician  and 
surgeon — to  one  for  the  alcoholization  of  the  great  nerve-trunks  for 
the  relief  of  neuralgia;  to  the  other,  for  the  purpose  of  regional  anes- 
thesia of  the  peripheral  parts,  as  well  as  for  the  deep  injections  of 
alcohol,  which,  in  its  clinical  application,  should  always  be  regarded 
as  a  surgical  procedure.  Whether  devised  originally  for  the  thera- 
peutic application  of  alcohol  or  the  proximal  cocainization  of  the 
nerve-trunks,  both  alike  serve  the  same  end  in  offering  an  approach 
to  the  nerve-trunks  and  can  alike  be  used  for  both  purposes. 

While  my  own  personal  experience  in  this  field  had  been  consider- 
able up  to  the  time  of  the  first  appearance  of  this  book  it  has  during 

S°7 


508  LOCAL   ANESTHESIA 

recent  years  been  very  materially  increased  until,  with  few  exceptions, 
the  entire  range  of  operations  upon  the  head  and  within  the  depth 
of  the  cranial  cavity  have  been  brought  within  the  scope  of  regional 
and  local  methods  and  often  with  surprising  ea.se  and  facility  when 
once,  the  difficulties  of  anesthesia  have  been  thoroughly  mastered 
and  overcome,  once  this  has  been  accomplished  the  advantages  of 
the  local  method  of  procedure  becomes  very  apparent  and  the  disad- 
vantage of  general  anesthesia  made  more  apparent.  This  is  par- 
ticularly the  case  in  extensive  resections  of  the  maxillae  where  the  ad- 
ministration of  the  general  anesthetic  has  many  difficulties,  the 
patient  may  be  constantly  swallowing  his  tongue  or  aspirating  blood 
and  mucus  and  the  avoidance  of  these  difficulties  necessarily  in- 
creases the  number  of  assistants  in  an  already  crowded  field  and  often 
causes  the  loss  of  much  time.  Within  the  cranial  cavity  the  conges- 
tion produced  by  the  general  anesthetic  often  causes  much  persistent 
oozing  which  adds  greatly  to  the  difficulties  and  accounts  for  much 
loss  of  time.  Under  local  means  these  difficulties  are  entirely  re- 
moved as  we  have  no  congestive  influences  at  work  and  the  normal 
vascularity  is  greatly  lessened  by  the  adrenalin  in  the  anesthetic 
solution. 

From  the  earlier  pioneer  efforts  in  this  direction  to  the  present 
time  are  to  be  found  a  galaxy  of  brillinat  names — Matas,  Schlosser, 
Ostwalt,  Hecht,  Lowenstein,  Killiani,  Patrick,  Bodine,  Keller,  Wright, 
Harris,  Braun,  Levy,  Baudoin,  Brissaud,  Sicard,  Taptas,  and  more 
recently  Offerhaus,  and  particularly  Hartel,  in  his  latest  approach  to 
the  gasserian  ganglion  and  exhaustive  presentation  of  this  subject. 

In  originally  undertaking  this  work  I  had  hoped  that  at  least  this 
chapter  would  be  from  the  pen  of  my  distinguished  chief,  Prof.  Matas, 
an  original  worker  in  this  as  well  as  other  fields,  and  whose  brilliant 
achievements  already  fill  many  pages  in  the  annals  of  surgery. 

While  deprived,  at  least  for  the  present,  of  this  benefit  due  to  the 
press  of  other  matters,  we  may  hope  that  should  this  chapter  be  re- 
written it  may  come  from  his  pen,  and  I  hope  that  in  this,  as  in 
other  chapters  of  this  work  in  which  I  have  so  freely  borrowed  from 
his  knowledge,  I  may  in  some  small  measure  reflect  credit  upon  his 
teachings. 

A  few  of  the  original  illustrations  in  this  chapter  are  from  the 
private  collection  of  Prof.  Matas,  kindly  loaned  for  this  purpose  and 
appear  for  the  first  time  in  these  pages.  These  illustrations  were 
prepared  by  my  colleague,  Dr.  Urban  Maes,  who,  in  association  with 
Prof.  Matas,  has  done  much  work  and  developed  great  skill  in  this  field. 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


509 


For  a  thorough  understanding  of  the  methods  of  local  and 
regional  anesthesia  applied  to  the  head  a  thorough  knowledge  of 
anatomy  is  essential,  with  a  study  of  the  subject  from  every  viewpoint; 
only  then  can  we  properly  appreciate  the  difficulties  and  delicate 
technic  necessary  for  the  clinical  application  of  these  methods. 


Fig.  146  — Diagram  of  the  fifth  cranial  nerve.     (From  Flower.) 

It  is  for  this  reason  that  the  minutiae  and  details  of  anatomy  have 
been  discussed  so  thoroughly  in  the  following  pages;  for  my  own 
part  this  study  has  been  of  immense  value  in  developing  any  pro- 
fiency  I  may  have  attained  in  this  field  and  I  cannot  too  strongly 
urge  the  necessity  of  its  careful  study  to  all  who  seek  success  here. 


LOCAL  ANESTHESIA 


Nowhere  else  in  the  entire  range  of  local  anesthesia  is  it  more  strongly 
emphasized  that  there  is  no  royal  road  to  success  in  local  anesthesia 
and  that  the  only  education  in  this  field  is  self-education. 


long  onauemosei  between  the  branrhrs  of  the 
I   Trigemfnus  and  ih, 
cer\iml  ncrvis 


supcrfic.  temporal 


cervical  >>r.  of  facial 


lerior  facial  «/•  ~ 


Fig.  147. — Superficial  nerves  and  arteries  of  the  face  (deeper  layer).  Most  of  the 
parotid  gland  is  removed.  The  facial  muscles  have  been  cut  away,  divided,  or  drawn 
downward.  (Sobotta  and  McMurrich.) 

The  Fifth  Nerve  and  Its  Branches  (Figs.  146, 147).— The  ophthal- 
mic or  first  division  of  the  fifth  (Fig.  148)  is  a  sensory  nerve,  supply- 
ing the  eyeball,  mucous  lining  of  the  eye,  lacrimal  gland,  nasal  fossa, 
the  skin  of  the  nose,  forehead,  and  front  portion  of  the  vertex.  After 
leaving  the  gasserian  ganglion  it  passes  forward  along  the  outer  wall 
of  the  cavernous  sinus,  below  the  other  nerves,  which  pass  here  (Fig. 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


215),  and  just  before  entering  the  orbit  through  the  sphenoidal  fissure 
divides  into  lacrimal  frontal  and  nasal  branches.  The  lacrimal 
branch  passes  forward  in  a  separate  tube  of  dura  mater,  and  enters 


frontal  r, 


supraorbital  art. 


SupratrocMcar 
nerve 


(ant.  meningeal 
art.) 


trochlear  net 

abiliicens  nrrvi 
tentorial  nen 
trigeminal  net 


andibular 
nerve 
semilunar  ganglion 


Fig.  148. — The  nerves  and  arteries  of  the  orbit  (superficial  layer).  The  roof  of  the 
orbit,  the  periorbita,  and  the  upper  portion  of  the  outer  wall  have  been  removed.  The 
dura  mater  has  been  divided  along  the  middle  meningeal  artery  and  in  the  neighborhood 
of  the  semilunar  ganglion  and  of  the  orbital  nerves.  *  =  Accessory  vessels  to  the  lacri- 
mal gland  from  the  zygomatico-orbital  branch  of  the  anterior  deep  temporal  artery. 
**  =  Orbital  fat.  (Sobotta  and  McMurrich.) 

the  orbit  at  the  narrowest  part  of  the  sphenoidal  fissure  (Fig.  169); 
it  then  runs  obliquely  forward  and  outward  above  the  upper  border 
of  the  external  rectus  to  the  lacrimal  gland. 

The  frontal,  the  largest  division  of  the  ophthalmic,  appears  as  a 


512  LOCAL   ANESTHESIA 

direct  continuation  of  this  nerve.  It  enters  the  orbit  above  the 
muscles  through  the  highest  and  broadest  part  of  the  sphenoidal 
fissure,  and  corftinues  forward  in  the  midline  between  the  levator 
palpebrae  and  the  periosteum  to  about  the  middle  of  the  orbit,  where 
it  divides  into  supratrochlear  and  supraorbital  branches. 

The  supratrochlear  (Fig.  147)  escapes  from  the  orbit  between  the 
pulley  of  the  superior  oblique  and  the  supraorbital  foramen;  it  curves 
up  on  the  forehead,  close  to  the  bone,  beneath  the  occipitofrontalis 
muscle,  and  is  distributed  to  the  skin  of  the  forehead  on  either  side 
of  the  middle  line. 

The  supraorbital  nerve  passes  forward  through  the  supraorbital 
foramen,  supplies  the  upper  eyelid,  and  ascends  beneath  the  occipito- 
frontalis muscle,  and  is  distributed  to  the  scalp  and  pericranium  as 
far  back  as  the  parietal  and  occipital  bones. 

The  nasal  nerve  enters  the  orbit  between  the  two  heads  of  the 
external  rectus,  passing  between  the  two  divisions  of  the  third  nerve, 
runs  obliquely  inward  above  the  optic  nerve,  beneath  the  superior 
oblique  and  superior  rectus  muscles  to  the  inner  wall  of  the  orbit, 
where  it  passes  through  the  anterior  ethmoidal  foramen,  giving  off  its 
infratrochlear  branch  here,  and  enters  the  cavity  of  the  cranium, 
where  it  traverses  a  groove  on  the  cribriform  plate  of  the  ethmoid 
bone  and  passes  down  through  the  slit  on  the  side  of  the  crista  galli 
into  the  nose.  Within  the  nasal  cavity  this  nerve  supplies  the  mucous 
membrane  in  its  upper  and  anterior  parts.  The  nerve  then  descends 
in  a  grove  on  the  back  part  of  the  nasal  bone,  escaping  between  the 
lower  border  of  this  bone  and  the  upper  lateral  cartilage  to  supply 
the  end  of  the  nose. 

Its  infratrochlear  branch  supplies  the  skin  at  the  inner  angle  of 
the  lids  and  side  of  the  nose. 

The  superior  maxillary  nerve  (Fig.  149)  passes  forward  through 
the  foramen  rotundum  into  the  sphenomaxillary  fossa,  passing 
obliquely  forward  and  outward.  It  enters  the  orbit  through  the 
sphenomaxillary  fissures,  and  passes  into  the  infra-orbital  canal  and 
appears  upon  the  face  at  the  infra-orbital  foramen,  where  it  divides 
into  three  sets  of  branches — palpebral,  nasal,  and  labial — which  are 
distributed  to  these  respective  parts  (Fig.  147).  In  the  sphenomaxil- 
lary fossa  this  nerve  gives  off  its  temporomalar,  sphenopalatine, 
and  posterior-superior  dental  branches. 

The  temporomalar  branch  enters  the  orbit,  and  divides  at  the 
back  part  of  this  cavity  into  temporal  and  malar  branches.  The 
temporal  branch  passes  through  a  foramen  in  the  malar  bone  and 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


513 


enters  the  anterior  part  of  the  temporal  fossa;  it  ascends  between  the 
bone  and  substance  of  the  temporal  muscle,  piercing  the  muscle  and 
temporal  fascia  about  i  inch  above  the  zygoma,  to  be  distributed  to 
the  skin  of  the  temporal  regions  and  side  of  forehead.  The-  malar 
branch  passes  through  a  foramen  in  the  malar  bone,  and  appears 


Fig.  149. — Innervation  of  the  teeth  (modified  from  Spalteholz).  The  outer  wall  of 
orbit  and  part  of  the  outer  wall  of  superior  and  inferior  maxillae  have  been  removed :  i ; 
Infra-orbital  nerve;  2,  3,  and  4,  posterior,  middle,  and  anterior  superior  dental  nerves, 
5,  sphenopalatine  ganglion  and  nerves;  6,  lateral  mucous  membrane,  antrum  of  High- 
more;  7,  inferior  dental  nerve;  8,  mental  nerve.  (From  Braun.) 

upon  the  cheek  at  the  opening  of  this  canal  (Fig.  147),  on  the  anterior 
surface  of  the  bone,  about  %  inch  below  the  rim  of  the  orbital  fossa, 
where  it  is  distributed  to  the  skin  of  the  cheek. 

The  sphenopalatine  descends  to  this  ganglion,  which  lies  just 
below  the  trunk  of  this  nerve  in  the  sphenomaxillary  fossa. 

33 


514  LOCAL   ANESTHESIA 

The  posterior  superior  dental  branches  are  given  off  from  the  supe- 
rior maxillary  nerve  in  the  sphenomaxillary  fossa,  just  as  it  is  about 
to  enter  the  orbit;  these  nerves  pass  down  over  the  tuberosity  of  the 
superior  maxillary  bone  to  enter  the  dental  canals  on  the  posterior 
surface  of  this  bone  about  its  midolle;  these  nerves  supply  the  three 
molar  teeth. 

The  middle  and  anterior- superior  dental  nerves  are  given  off  in  the 
infra-orbital  canal,  the  middle  supplying  the  two  bicuspids,  the 
anterior  branch  the  canine  and  incisor  teeth. 

The  descending  or  palatine  branches  from  the  sphenopalatine 
ganglion  are  three  in  number — anterior,  middle,  and  posterior.  The 
anterior  descends  through  the  posterior  or  palatine  canal  to  appear 
upon  the  hard  palate  at  the  posterior  palatine  foramen;  it  then 
passes  forward  in  a  groove  at  the  junction  of  the  hard  palate  and 
alveolar  process,  nearly  as  far  as  the  incisor  teeth,  supplying  the 
parts  in  the  vicinity  of  its  distribution.  In  the  palatine  canal  it 
gives  off  branches  to  the  nasal  fossa.  The  middle  and  posterior 
branches  are  distributed  to  the  soft  palate  and  tonsillar  regions. 

The  nasopalatine  nerve  is  the  only  other  nerve  from  the  spheno- 
palatine ganglion  which  is  of  special  interest.  It  enters  the  nasal 
fossa  through  the  sphenopalatine  foramen,  passes  inward  across  the 
roof  of  the  nasal  fossa  to  reach  the  septum,  down  which  it  runs  to 
the  anterior  palatine  foramen,  and  appears  at  the  opening  of  this 
canal  on  the  roof  of  the  mouth  to  supply  the  surrounding  soft  parts. 

The  inferior  maxillary  nerve,  largest  division  of  the  fifth,  passes 
through  the  foramen  ovale  and  divides  into  two  trunks — anterior 
and  posterior.  It  is  joined  at  this  point  by  its  motor  root,  most  of 
which  passes  into  its  anterior  division,  which  divides  into  masseteric, 
buccal,  and  pterygoid  branches,  to  be  distributed  to  these  muscles, 
the  masseteric  passing  through  the  sigmoid  notch  to  reach  this 
muscle;  the  buccal  branch,  in  addition  to  supplying  this  muscle,  is 
distributed  to  the  skin  of  the  cheek  as  far  forward  as  the  angle  of  the 
mouth. 

The  deep  temporal  branches,  given  off  just  after  the  nerve  emerges 
from  the  skull  and  running  outward  and  upward,  are  distributed  to 
the  temporal  muscle. 

The  auriculotemporal  nerve  curves  upward  with  the  temporal 
artery,  between  the  external  ear  and  condyle  of  the  jaw,  beneath 
the  substance  of  the  parotid  gland,  and,  passing  over  the  zygoma, 
divides  into  branches — auricular,  superior,  and  inferior,  and  a  branch 
to  the  meatus  auditorius,  which  are  distributed  to  these  parts.  The 


TH*    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  515 

temporal  branches  pass  upward  with  the  temporal  artery  and  supply 
the  scalp  as  far  as  the  vertex  of  the  skull. 

The  lingual  nerve  reaches  the  inner  side  of  the  ramus  of  the  jaw, 
down  which  it  descends  on  the  inner  side  of  the  dental  nerve  to  the 
base  of  the  tongue,  crossing  obliquely  forward  and  inward  to  this 
organ,  running  along  its  side  as  far  as  the  tip.  Where  the  nerve 
passes  from  the  ramus  of  the  jaw  to  the  base  of  the  tongue  it  is  quite 
superficially  situated  beneath  the  mucous  membrane,  and  is  quite 
easily  reached  in  this  position,  particularly  if  the  tongue  is  drawn  for- 
ward and  to  the  opposite  side. 

The  inferior  dental  neroe  passes  obliquely  downward,  forward,  and 
outward  with  the  inferior  dental  artery  to  reach  the  dental  foramen 
on  the  inner  side  of  the  inferior  maxilla.  In  the  dental  canal  it  gives 
off  branches  which  supply  the  teeth,  and  a  mental  branch,  which 
appears  at  the  mental  foramen  and  supplies  the  lower  lip  and  the 
soft  parts  of  the  chin. 

In  addition  to  the  branches  of  the  fifth  the  lower  part  of  the  face 
receives  branches  from  the  cervical  nerves.  The  side  of  the  head 
receives  the  auricular  branch  of  the  pneumogastric,  which  passes 
upward  between  the  mastoid  process  and  external  auditory  meatus 
to  the  back  of  the  ear.  The  occipital  region  is  supplied  by  the 
occipitalis  major  and  minor  and  the  auricularis  magnus.  These 
nerves  will  be  spoken  of  in  dealing  with  their  areas  of  distribution. 

Anesthesia. — To  anesthetize  the  supra-orbital  and  supratrochlear 
nerves  an  injection  of  about  2  drams  of  solution  No.  2, 0.50  per  cent, 
novocain,  and  a  few  drops  of  adrenalin  to  the  ounce  should  be  made 
just  over  the  supra-orbital  notch,  beneath  the  deep  frontal  fascia, 
transversely  for  about  i  inch;  or,  where  both  nerves  are  to  be  in- 
jected, this  can  be  done  by  a  subfascial  injection,  extending  across 
the  base  of  the  forehead,  as  indicated  in  Fig.  150,  the  shaded  portion 
indicating  the  anesthetic  area;  on  the  margins  of  this  area  for  some 
distance  back  there  is  lessened  sensibility.  While  it  is  quite  feasible 
to  practice  strictly  regional  anesthesia  for  the  entire  scalp  by  blocking 
the  supra-orbital  nerves  in  front,  the  occipital  nerves  behind,  and  the 
temporal  nerves  on  the  side  by  a  line  of  anesthesia  just  above  the 
zygoma,  extending  from  the  ear  to  the  angle  of  the  orbit  and  carried 
down  to  beneath  the  temporal  fascia,  thus  rendering  the  entire  scalp 
anesthetic.  This  procedure  limitd  to  one  side  produces  an  anesthe- 
sia reaching  almost  to  the  vertex,  where  the  nerves  of  the  opposite 
side  lap  over.  Such  an  extensive  area  of  anesthesia  is,  not  often 
called  for,  while  anesthesia  of  those  parts  supplied  by  the  supra- 


LOCAL   ANESTHESIA 


orbital  and  occipital  nerves  will  more  often  be  found  quite  useful, 
easily  and  quickly  carried  out;  but  where  the  field  of  operation  is 
more  or  less  central  on  the  scalp,  it  will,  usually  be  found  simpler 
and  require  less  solution  to  surround  the  operative  area  by  a  wall  of 


LJ 


Fig.  150. — Resulting  area  of  anesthesia  after  blocking  supra-orbital  and  supratrochlear 
nerves  along  heavily  shaded  line.     (From  Braun.) 

anesthesia  carried  well  down  to  the  pericranium,  which  will  meet  and 
anesthetize  all  nerves  entering  the  area  and  permit  any  contemplated 
operation  upon  the  soft  parts,  as  well  as  resections  of  the  bone  and 
operations  upon  the  underlying  dura  and  brain  (Figs.  151,  152). 


Fig.  151. — Surrounding  tumor  of  the  scalp  with  zone  of  anesthesia.     (From  Braun.) 

Here  the  operative  field  is  surrounded  by  an  area  of  anesthesia, 
and  at  several  points  along  this  surrounding  zone  the  long  needle  is 
entered  and  passed  down  to  the  bone  through  the  points  indicated 
by  the  heavy  dots,  injecting  the  solution  as  the  needle  is  advanced. 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


517 


However,  it  is  to  be  recommended,  as  a  general  rule,  that  all 
extensive  operations  upon  the  soft  parts  or  underlying  bone  in  the 
region  supplied  by  the  fifth  nerve  be  operated  by  injections  of  gan- 
glion gasseri,  or  its  nerves  at  their  foramina  of  exit;  the  injection  of 
the  ganglion  has  the  advantage  that  it  anesthetizes  the  dura  through 
its  meningeal  branches  as  well  as  the  overlying  bone  and  soft  parts. 

As  the  occipital  nerves  are  several  in  number,  and  reach  the 
scalp  at  different  points,  they  may  be  dealt  with  collectively.  If  a 
line  of  anesthesia  (solution  No.  2,  with  5  drops  adrenalin  to  the  ounce) 
is  produced,  extending  from  ear  to  ear  across  the  base  of  the  mastoid 


Fig.  152. — Surrounding  a  compound  fracture  of  skull  with  zone  of  anesthesia.     (From 

Braun.) 

processes,  and  carried  well  down  to  the  deep  tissues,  it  will  block  all 
branches  of  the  occipital  nerves,  as  well  as  branches  from  the  auricu- 
laris  magnus,  and  result  in  an  anesthetic  area,  as  indicated  in  Fig. 
154  (the  black  line  shows  the  line  of  infiltration),  or  the  nerves  may 
be  dealt  with  more  or  less  individually  in  the  following  way: 

The  occipitalis  major  and  minor  and  the  auricularis  magnus  may 
be  blocked  by  making  injections  at  their  points  of  emergence  at  the 
occiput  (Fig.  154);  the  occipitalis  minor  and  auricularis  magnus 
behind  the  posterior  margin  of  the  insertion  of  the  sternocleido- 
mastoid.  The  occipitalis  major  emerges  upon  the  surface  of  the 


LOCAL   ANESTHESIA 


occiput  through  a  cleft  in  the  trapezius  muscle,  along  with  the  occipi- 
tal artery,  the  third  occipital,  sometimes  an  independent  nerve,  pass- 


great  occipital  ner 
occipital  vessels.  A 


Occipitalis 

'ccipital  artery 
real  occipital  nerve 
occipital  vein 

'  occipital  nerve 


descend.br.  of  transv.  cervical  art.   'Le 
descend,  b,:  oftrantv.  cervical  Vfia 


Latissinuis 

dorsi 


posterior  cutaneous  branches  of  intercostal  nerves- 


Fig.  153. — The  superficial  and  middle  layer  of  the  nerves  and  vessels  of  the  nuchal 
region.  Upon  the  left  side  the  trapezius,  sternocleidomastoideus,  splenius,  and  leva  tor 
scapulas  have  been  divided.  *  =  Occipital  root  of  external  jugular  vein.  (Sobotta  and 
McMurrich.)  • 


ing  slightly  nearer  the  midline;  to  reach  both  of  these  nerves  a  deep 
line  of  infiltration  can  be  carried  from  the  posterior  occipital  protu- 


berance  one-third  of  the  distance  between  the  auricle.  As  empha- 
sized by  Hartel,  and  referred  to  by  Bier  and  Krause,  in  intracranial 
operations  regional  methods  of  anesthesia  should  be  preferred 
to  infiltration  around  the  operative  area  in  such  operations  where 
the  electric  excitability  of  the  cerebral  cortex  should  not  be  dis- 
turbed, as  in  operations  for  epilepsy.  When  performing  such 
operations  under  infiltration  anesthesia  the  diffusion  of  the  anes- 
thesia may  reach  the  cerebral  cortex  and  interfere  with  electric 


Fig.  154. — Line  of  subcutaneous  infiltration  blocking  occipital  and  auricularis  magnus 
nerves  and  resulting  area  of  anesthesia. 

tests.  It  must  be  remembered  that  here  as  elsewhere  bone  is  insen- 
sitive to  pain  after  the  periosteum  has  been  anesthetized  or  denuded, 
and  it  can  be  freely  operated  upon  with  trephine,  chisel,  rongeur,  or 
saw  without  the  least  discomfort,  beyond  the  fact  that  the  patient 
hears  and  feels  the  jar  of  the  manipulations.  The  dura  is  insensitive 
to  wounds  inflicted  through  incisions  or  the  application  of  forceps, 
but  is  sensitive  to  traction  should  it  be  pulled  upon,  consequently 
it  can  be  freely  incised  and  turned  back  without  pain.  This  state- 
ment holds  good  for  the  vertex  and  lateral  surfaces  of  the  brain, 
the  areas  most  frequently  operated  upon;  however,  at  the  base  of 
the  skull,  where  the  dura  is  attached  to  the  bone,  some  painful  sen- 
sations are  experienced,  requiring  infiltration  of  the  dura  here  to 
permit  of  its  incision  or  removal  from  the  bone,  but  the  operative 
procedures  in  these  areas  are  comparatively  few,  and  when  necessary 


520  LOCAL    ANESTHESIA 

it  is  quite  easy  to  anesthetize  the  dura  here  by  progressive  injections 
as  you  advance. 

It  is  a  remarkable  fact  that  the  brain,  the  great  sensory  organ  of 
the  body,  should  itself  be  devoid  of  painful  sensations.  The  entire 
cerebral  cortex  of  animals  has  been  irritated  and  stimulated  in  many 
ways  without  ever  exciting  any  response  indicative  of  pain,  and  we 
have  often  removed  considerable  areas  from  the  brain  of  a  thoroughly 
conscious  patient  without  ever  exciting  any  pain. 

The  knowledge  of  these  facts  permits  us  to  undertake  in  suitable 
cases  many  operations  under  local  anesthesia  upon  the  skull  and 
brain  which  might  otherwise  seem  impossible.  In  any  extensive 
operation  upon  the  cranium  it  may  prove  desirable  to  use  circular 
constriction,  with  rubber  tubing  around  the  base  of  the  cranium; 
this,  however,  while  often  advisable  with  general  anesthesia,  is 
superfluous  with  local  methods,  for  here  the  use  of  adrenalin  proves 
an  effective  hemostatic,  besides  the  constriction  is  often  in  the  way, 
and  may  prove  annoying  or  painful  to  any  but  a  patient  under 
general  anesthesia  unless  the  entire  circumference  of  the  cranium 
were  anesthetized.  Usually  in  severe  traumatisms  of  the  skull,  such 
as  extensive  or  simple  depressed  fractures,  the  patients  are  often 
in  a  state  of  unconsciousness  from  shock  or  brain  injuries,  which 
permit  of  painless  operating  with  very  little  local  anesthesia.  On 
the  other  hand,  many  of  these  patients  are  in  a  condition  of  noisy 
delirium  or  turbulent  restlessness,  which  makes  any  operation  under 
local  anesthesia,  even  if  painless,  inadvisable,  and  forces  a  resort  to 
general  anesthesia. 

Omitting  the  above  class  of  patients,  there  are  a  large  range  of 
operations  which  permit  of  the  use  of  local  anesthesia.  Simple 
abscesses  will  require  nothing  further  than  a  line  of  infiltration  over 
the  proposed  incision. 

Wounds. — For  the  cleansing  and  suture  of  incised,  contused,  and 
lacerated,  stab  or  superficial  gunshot  wounds,  the  most  satisfactory 
plan  is,  after  a  preliminary  cleansing  of  the  surrounding  parts,  to 
create  a  wall  of  anesthesia  around  the  wound,  cleansing  it  later  with 
a  more  liberal  cleansing  of  the  entire  area  after  the  anesthetizing 
process  has  been  completed,  as  described  in  the  chapter  on  Principles 
of  Technic. 

Sebaceous  cysts  may  be  removed  the  same  way,  by  a  surrounding 
wall  of  anesthesia  and  excising  a  triangular  or  oblong  piece  of  the 
skin  with  the  tumor  attached,  approximating  the  gap  with  sutures; 
or  by  infiltrating  a  line  over  the  long  axis  of  the  cyst  and  splitting  it 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  521 

open  and  pealing  out  the  sac.  While  this  is  a  simple  and  thoroughly 
effective  method  in  non-infected  sacs,  in  the  event  of  infection  it  will 
leave  a  suppurating  wound. 

Benign  tumors  may  be  dealt  with  by  the  same  method,  also  malig- 
nant growths  when  superficial  and  limited,  as  in  epitheliomas,  but  if 
extensive  or  deeply  infiltrating  had  best  be  left  to  regional  methods  or 
general  anesthesia.  In  those  cases  of  malignancy  suitable  for  local 
methods  care  should  be  exercised  in  making  the  injections  to  keep 
well  away  from  the  growth,  and  surround  it  by  a  wall  of  anesthesia, 
extending  down  to  the  cranium,  so  that  this  may  be  resected  if  the 
growth  is  found  attached. 

As  this  same  technic  is  applicable  to  all  operations  upon  the  scalp 
and  underlying  bone,  it  is  sufficient  to  state  that  it  is  suitable  in 
depressed  iractures  and  for  the  evacuation  of  epidural  or  subdural 
hemorrhage,  intracranial  abscesses,  and  for  the  removal  of  necrotic 
areas  of  the  skull.  Osteoplastic  flaps  of  considerable  extent  are  also 
just  as  easily  raised  with  local  anesthesia  and  operations  performed 
upon  the  cortex  of  the  brain.  Here  local  anesthesia  possesses  de- 
cided advantages  over  general  anesthesia,  particularly  ether,  which 
greatly  congests  the  entire  cranial  circulation,  and  is  particularly 
troublesome  when  operating  within  the  skull  on  account  of  the  per- 
sistent oozing  which  occurs  from  even  the  smallest  vessels,  and  greatly 
adds  to  the  danger  of  postoperative  hematoma.  This  entire  picture 
is  changed  when  operating  with  local  anesthesia;  instead  of  the  tre- 
mendous congestion  encountered,  with  ever-ready  tendency  to 
troublesome  hemorrhage  difficult  to  control,  with  possible  later 
oozing,  the  brain  and  its  circulation  is  found  normal,  and  hemorrhage 
either  does  not  occur,  or  is  easily  controlled,  with  little  or  no  tend- 
ency to  postoperative  oozing. 

For  this  reason,  if  for  no  other,  it  is  advised  to  consider  local 
anesthesia  in  all  suitable  intracranial  operations,  and  when  the  opera- 
tion is  extensive  to  perform  it  by  a  two-stage  operation,  raising  the 
osteoplastic  flap  in  the  first  stage  under  general  anesthesia;  this  is 
then  returned  to  its  place  and  lightly  held  with  sutures,  to  be  again 
raised  at  a  subsequent  sitting,  next  day  or  later,  the  dura  opened, 
and  the  intradural  procedure  executed. 

The  advantage  of  this  method  is  illustrated  by  the  following 
reports : 

Mr.  S.,  very  stout,  short  man,  weighing  over  200  pounds,  gave  symptoms  of  tumor 
near  left  motor  area.  Under  general  anesthesia  a  large  osteoplastic  flap  was  raised,  ex- 
posing the  entire  left  motor  area.  The  patient  was  very  full  blooded,  and  the  entire 
circulation  of  the  head,  face,  and  cerebrum  became  greatly  congested;  the  cerebral  and 


522  LOCAL    ANESTHESIA 

meningeal  vessels  were  everywhere  turgid  with  blood,  and  would  certainly  have  given 
trouble  if  the  operation  had  been  proceeded  with;  accordingly  the  wound  was  loosely 
closed,  after  securing  all  bleeding-points  in  the  external  soft  parts,  and  the  patient 
returned  to  bed.  The  next  day,  after  lightly  injecting  a  cocain  solution  into  the  incision, 
the  sutures  were  loosened  and  the  flap  raised;  beyond  this  point  no  coeain  was  used. 
The  operation  was  everywhere  painless,  the  patient  conversing  with  us  during  the  differ- 
ent steps  of  the  deeper  procedure.  A  vast  difference  was  now  seen  in  the  condition  of 
the  meningeal  and  cerebral  circulation,  the  vessels  which  previously  had  been  turgid 
with  blood  were  now  hardly  to  be  seen,  only  a  few  small  vessels  of  normal  size  encoun- 
tered here  and  there.  The  brain,  which  had  previously  been  tense  and  bulging  from  the 
wound,  now  seemed  shrunken  by  comparison  and  lay  well  within  the  skull. 

Two  tumors  were  located  back  of  the  motor  area  and  removed  with  a  surrounding 
margin  of  brain,  resulting  in  a  paresis  of  the  right  side  of  the  body  and  tongue.  The 
patient  was  able  to  indicate  during  the  entire  procedure  that  he  felt  no  pain.  The 
wound  was  then  closed  with  a  small  drain,  the  patient  making  a  satisfactory  recovery, 
but  died  about  six  months  later  from  a  recurrence  of  the  malignant  process.  This  case 
illustrates  clearly  the  advantages  of  a  two-stage  operation,  or  the  entire  procedure  could 
have  been  performed  at  one  sitting  with  local  anesthesia.  The  subsequent  stage  could, 
however,  have  been  done  without  any  anesthesia,  a  preliminary  hypodermic  of  an 
eighth  or  quarter  of  morphin  would  have  sufficed  to  relieve  the  fears  and  uneasiness  of 
the  patient;  the  raising  of  the  flap  by  the  second  day  would  not  have  caused  any  amount 
of  pain,  and,  as  the  deeper  parts  are  without  sensations,  the  second  stage  may  possibly 
have  been  performed  this  way. 

This  and  many  other  experiences  have  strongly  convinced  me 
of  the  advantages  of  using  local  anesthesia  in  suitable  cranial  and  in- 
tracranial  operations  upon  favorable  patients,  where  it  is  known  be- 
forehand just  what  is  going  to  be  done  and  the  parts  are  all  fairly 
accessible. 

The  following  case  illustrates  a  very  satisfactory  and  fairly  exten- 
sive operation  for  the  removal  of  necrotic  bone  and  drainage  of  an 
epidural  abscess: 

G.  W.  L.  entered  our  service  in  the  Delgado  Memorial,  March,  1911,  with  a  history 
of  a  luetic  infection  nine  years  before.  There  were  multiple  gummas  about  the  head, 
with  a  sinus  over  the  right  ear  which  ran  down  to  the  bone,  also  a  fluctuating  mass  3 
inches  above,  which  seemed  to  communicate  with  the  sinus.  Operation  under  local 
anesthesia  (the  patient  in  poor  physical  condition),  a  wall  of  anesthesia  was  created  with 
solution  No.  i,  which  ran  from  the  ear  below  to  the  midline  of  the  vertex  above  and 
measured  about  3  inches  across;  this  wall  of  anesthesia  was  carried  well  down  to  the  peri- 
cranium. In  a  few  minutes  anesthesia  in  the  central  area  was  complete.  An  incision 
was  made  down  to  the  bone  connecting  the  swelling  above  with  the  sinus  below;  the 
swelling  was  found  to  be  broken-down  gumma  over  a  necrotic  area  in  the  skull  which 
communicated  with  the  sinus  below;  the  bone  was  removed  between-  these  two  points, 
and  revealed  multiple  areas  of  necrosis  on  the  inner  table  of  the  skull  with  numerous 
small  sequestra;  in  all  an  irregular  area  of  the  skull  was  removed  which  measured  about 
2  by  3  inches.  The  outer  surface  of  the  dura,  which  was  covered  with  foul  granula- 
tions, was  then  curetted  and  the  wound  packed  and  skin  edges  approximated.  The 
patient  was  later  given  606,  and  discharged  when  the  wound  in  the  head  had  healed. 
He  returned  again  the  following  October  with  a  similar  condition  near  the  site  of  the 
first  operation,  and  was  operated  on  in  a  similar  way.  Both  operations  were  entirely 
painless,  and  were  performed  as  thoroughly  as  would  have  been  the  case  under  a  general 
anesthetic. 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  523 

A  very  interesting  case  of  a  similar  nature,  illustrating  the  advan- 
tages of  a  two-stage  operation,  or  of  performing  the  entire  operation 
under  local  anesthesia,  is  the  following,  reported  by  Drs.  Thomas  and 
Gushing  in  the  "Journal  Amer.  Med.  Assoc.,"  March  14,  1908:  The 
case,  a  rather  dangerous  one,  had  been  operated  on  four  times  for  a 
tumor  of  the  upper  posterior  Rolandic  area.  Much  difficulty  was 
experienced  from  hemorrhage,  due  to  the  fulness  of  the  vessels  pro- 
duced by  the  anesthetic  and  forced  an  abandonment  of  the  operation, 
the  patient  also  doing  badly  under  the  anesthetic.  One  operative 
intervention  was  made  necessary  for  the  removal  of  clots  which  re- 
sulted from  the  free  oozing  from  the  congested  vessels. 

The  fifth  and  last  operation,  at  which  time  the  cyst  was  removed, 
was  done  under  cocain  anesthesia,  a  preliminary  hypodermic  of 
}^  gr.  of  morphin  and  ^{QO  gr.  of  atropin  given  a  short  time  before. 
The  following  are  extracts  from  Dr.  Cushing's  notes: 

"Although  the  undertaking,  as  Dr.  Thomas  has  said,  was  pre- 
meditated, etc.,  in  consequence  of  our  previous  unfortunate  expe- 
rience in  administering  general  narcosis  to  this  patient  we  must  con- 
fess to  surprise  at  its  successful  accomplishment.  Contrary  to  all 
expectations,  the  dura  proved  to  be  insensitive  to  such  manipulations 
as  were  necessary  to  freely  open  it.  Only  when  it  was  put  under 
tension  or  displacement  was  any  discomfort  occasioned,  otherwise 
it  seemed  to  be  absolutely  free  from  sensitivity.  The  conditions 
were  similar  in  many  respects  to  those  which  are  present  in  the  vis- 
ceral peritoneum,  which,  according  to  Lennander,  as  well  as  our  own 
observations,  seem  to  possess  no  sensory  nerves,  pain  being  occa- 
sioned only  when  the  viscera  are  so  dislocated  as  to  put  the  pa- 
rietal serosa  under  abnormal  tension. 

"The  danger  of  doing  all  the  operation  at  one  stage,  owing  to 
hemorrhage,  made  greater  by  the  congestion  brought  about  by  the 
anesthesia.  If  it  should  prove  to  be  possible,  however,  to  carry  out 
the  second  stage  of  an  intracranial  exploration  without  an  anesthetic, 
this  would  be  a  stronger  argument  for  the  two-stage  procedure  than 
the  mere  avoidance  of  shock. 

"It  was  truly  remarkable  in  this  patient's  case  to  find  that  the 
extensive  manipulations  which  were  essential  to  the  removal  of  the 
tumor  could  be  carried  out  while  the  patient  was  perfectly  conscious, 
and  was  chatting  and  taking  a  lively  interest  in  the  progress  of  the 
operation." 

Numerous  other  cases  could  be  mentioned  in  our  own  practice,  as 
well  as  in  that  of  others,  but  the  above  will  suffice  to  illustrate  the 


524 


LOCAL   ANESTHESIA 


technic  and  possible  extent  of  many  cranial  and  intracranial  opera- 
tions. 

Subtemporal  Decompression. — This  procedure  illustrates  the 
method  of  anesthesia  in  craniotomy  which  with  little  variations  to 
suit  the  case  can  be  applied  to  many  operations  on  the  skull.  The 
field,  as  outlined  in  Fig.  155,  shows  the  area  for  injection  and  the 
most  convenient  points  for  entering  the  long  needle.  By  following 
a  methodical  plan  as  is  advocated  for  all  typical  procedures  the  de- 
tails of  anesthesia  are  quickly  executed  with  but  little  time  and  the 


Fig.  155. — Points  of  injection  and  line  of  infiltration  for  craniotomy  in  temporal  region. 

(From  Braun.) 

work  greatly  facilitated.  The  entire  field  is  injected  before  the 
operation  is  begun.  Make  an  intradermal  wheal  at  point  i,  Fig. 
155,  just  above  the  zygomatic  arch  enter  the  long  needle  at  this  point 
and  direct  it  down  to  the  bone  through  the  substance  of  the  temporal 
muscle  injecting  as  it  is  advanced,  slightly  withdraw  the  needle 
and  redirect  it  at  a  slight  lateral  angle  again  passing  it  down  to  the 
bone.  The  same  procedure  is  repeated  in  the  opposite  direction, 
always  injecting  as  the  needle  is  advanced.  The  point  of  the  needle 
is  now  withdrawn  until  it  is  just  beneath  the  skin,  when  it  is  directed 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  525 

laterally;  injecting  as  it  is  advanced  in  the  subcutaneous  tissues  above 
the  ear  or  as  far  back  as  the  proposed  field  of  operation.  The  same 
procedure  is  repeated  in  the  opposite  direction  toward  the  supra -or- 
bital ridge.  The  needle  is  now  entered  along  this  horizontal  line  first 
from  one  end  and  then  the  other  and  directed  up  over  the  head, 
injecting  first  subcutaneously  and  then  deeply  beneath  the  tem- 
poral muscle  but  above  the  temporal  muscle  in  the  upper  parts  of 
the  field  the  subcutaneous  injections  are  sufficient.  By  entering  the 


Fig.  156. — Points  for  deep  injections  and  line  of  infiltration  for  carniotomy  over  cere- 
bellum.    (From  Braun.) 

needle  at  one  or  two  additional  points  these  subcutaneous  lines  of 
anesthesia  are  made  to  meet  over  the  upper  part  of  the  field.  No 
further  anesthesia  is  needed  and  the  operation  can  be  proceeded 
with  and  done  by  any  method  preferred.  Usually  by  turning  down 
the  skin  flap  and  splitting  the  muscle  longitudinally  when  it  can  be 
sufficiently  retracted  to  permit  of  the  use  of  bone  instruments. 
The  bone  will  be  found  insensitive  as  well  as  the  dura  and  brain. 
All  bone  instruments  for  use  with  local  anesthesia  should  be  sharp 
to  lessen  the  shock  which  is  always  unpleasant.  In  Fig.  156  is 


526  LOCAL   ANESTHESIA 

figured  the  operative  area  and  points  of  injection  for  operations  upon 
the  occipital  region, as  well  as  for  exposing  the  surface  of  the  cerebellum. 

To  locate  the  supra-orbital,  infra-orbital,  and  mental  foramina, 
Gray  gives  the  following  directions:  "The  supra-orbital  foramen  is 
situated  at  the  junction  of  the  internal  and  middle  third  of  the  supra- 
orbital  arch,  between  the  internal  and  external  angular  processes. 
If  a  straight  line  is  drawn  from  this  point  to  the  lower  border  of  the 
inferior  maxillary  bone,  so  that  it  passes  between  the  two  bicuspid 
teeth  in  both  jaws,  it  will  pass  over  the  infra-orbital  and  mental  fora- 
mina, the  former  being  situated  about  i  cm.  (%  inch)  below  the 
margin  of  the  orbit.  The  latter  varying  in  position  according  to  the 
age  of  the  individual.  In  the  adult  it  is  midway  between  the  upper 
and  lower  borders  of  the  inferior  maxillary  bone,  in  the  child  it  is 
nearer  the  lower  border  and  in  the  edentulous  jaw  of  old  age  it  is 
close  to  the  upper  margin"  (Fig.  163). 

The  infra-orbital  foramen  is  situated  about  i  cm.  below  the  or- 
bital margin,  about  midway  between  the  inner  and  outer  angles,  its 
axis  directed  downward,  forward,  and  inward,  a  continuation  of 
this  line  passing  just  over  the  middle  incisor  teeth. 

The  foramen  is  subjected  to  considerable  variations,  more  par- 
ticularly as  to  size,  occasionally  being  so  small  as  to  be  difficult  of 
entrance  with  a  needle  when  exposed  by  open  dissection,  its  position 
and  axis  also  vary  slightly.  However,  the  above  will  be  found  ap- 
proximately correct  in  the  great  majority  of  skulls. 

If  a  point  of  anesthesia  be  established  on  the  cheek  over  the  recog- 
nized position  of  this  foramen,  and  the  needle  advanced  from  the 
middle  line  below,  keeping  the  syringe  in  contact  with  the  midline  of 
the  lip,  and  injecting  as  the  needle  is  advanced,  when  after  coming  in 
contact  with  the  bone  the  canal  can  be  sought  for  and  often  entered 
when  sufficiently  patulous;  when  this  cannot  be  done  the  injection 
should  be  made  deep  down  in  close  contact  with  the  bone  and  just 
below  the  known  position  of  the  foramen;  i  to  2  c.c.  of  a  2  per  cent, 
novocain-adrenalin  solution,  when  deposited  at  this  point  on  both 
sides,  produces  anesthesia  after  five  to  ten  minutes.  The  anesthetic 
area  is  shown  in  Fig.  164,  as  well  as  the  underlying  bone. 

The  infra-orbital  and  mental  nerves  can  be  reached  at  the  fora- 
mina through  the  mouth  but  when  done  careful  asepsis  should  be 
observed.  It  is  impossible  to  get  the  needle  within  the  canal  from 
the  position  but  it  can  be  deposited  at  the  opening.  It  is,  however, 
much  better  to  follow  the  first-mentioned  method  and  make  the 
injection  within  the  canal.  The  infra-orbital  foramen  is  located  by 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  527 

the  tip  of  the  finger,  and  is  found  just  above  the  root  of  the  first 
bicuspid,  about  %  to  i  cm.  below  the  rim  of  the  orbital  fossa  (Fig. 
162).  With  the  finger  held  at  this  point,  the  lip  is  raised  and  the 
needle  entered  high  up  slightly  posterior  to  the  root  of  the  canine 
tooth,  and  some  little  distance  from  the  bone  nearer  the  labial  than 
the  alveolar  attachment  of  the  mucous  membrane,  so  that  the 
needle  in  being  advanced  can  be  directed  slightly  backward  and 
upward  (Fig.  163).  The  solution  is  injected  as  the  needle  is  ad- 
vanced, until  its  point  is  felt  just  under  the  palpating  finger  which 
locates  the  foramen;  as  the  nerve  hugs  the  bone  in  this  position, 
dividing  into  palpebral,  nasal,  and  labial  branches,  the  injection 
must  be  made  deep  down  in  close  contact  with  the  bone;  about 
2  drams  of  a  i  per  cent,  novocain-adrenalin  solution  is  required, 
and  in  about  ten  minutes,  if  properly  made  on  both  sides,  should 
produce  an  area  of  anesthesia,  as  shown  in  Fig.  164.  This  injection 
when  well  made  diffuses  back  into  the  infra-orbital  canal  and  reaches 
the  anterior  superior  dental  nerves,  whLch  are  given  off  but  a  short 
distance  back  of  the  foramen  and  supply  the  canine  and  incisor  teeth 
(Figs.  149,  165). 

Intraneural  Injections  at  the  Mental  Foramen. — The  mental 
foramen  is  situated  at  the  base  of  the  alveolar  process,  between 
the  first  and  second  bicuspids.  The  lip  is  reflected,  and  the  needle 
advanced  in  this  direction  from  the  depth  of  the  mucous  fold  close 
down  to  the  bone  (Fig.  163),  injecting  as  the  needle  is  advanced, 
depositing  about  >£  to  i  dram  of  i  per  cent,  novocain-adrenalin 
solution  within  the  foramen. 

As  the  terminal  fibers  of  the  inferior  dental  nerve,  both  within 
the  bone  at  the  symphysis  as  well  as  after  emerging  from  the  mental 
foramen,  freely  intermingle  with  the  branches  of  the  opposite  side,  it 
is  necessary  in  operating  in  this  region  to  inject  both  sides. 

The  free  intermingling  of  the  nerve,  which  takes  place  at  the 
symphysis,  limits  the  extent  of  anesthesia,  which  takes  place  follow- 
ing the  injection  of  the  inferior  dental  nerve  of  one  side  to  about 
the  position  of  the  first  bicuspid  of  that  side,  but  can  be  made 
to  extend  well  beyond  the  middle  line  by  a  mental  injection  of  the 
opposite  side. 

Intraneural  injections  at  the  mental  foramen  made  from  without 
are  done  in  the  following  manner:  after  locating  the  approximate 
position  of  the  foramen,  which  is  directed  upward  and  backward  and 
lies  between  the  two  bicuspids  at  a  variable  distance  from  the  infe- 
rior margin  of  the  maxilla,  depending  upon  the  age  of  the  individual, 


528  LOCAL   ANESTHESIA 

in  infancy  being  near  its  lower  border;  in  adult  life,  about  i  cm.  or 
slightly  more  above;  in  edentulous  old  age,  lying  near  the  alveolar 
margin. 

The  needle  is  directed  obliquely  downward,  forward,  and  inward 
in  the  axis  of  the  foramen,  injecting  as  it  is  advanced ;  after  reaching 
the  bone,  the  foramen  is  searched  for,  and,  if  possible,  entered;  if 
not,  the  injection  made  over  its  orifice,  but  the  foramen  is  nearly 
always  patulous  and  readily  entered. 

If  the  injection  can  be  made  within  the  canal  or  time  allowed, 
ten  to  fifteen  minutes,  if  the  injection  is  made  over  the  foramen,  the 
solution  diffuses  into  the  canal,  and  the  resulting  anesthesia,  when  in- 
jecting on  both  sides,  involves  the  lower  lip  and  tissues  of  the  chin, 
the  gum  on  its  labial  side,  the  teeth  between  the  two  foramina,  and 
the  involved  bone ;  the  mucous  membrane  and  gum  on  the  inner  side 
are  not  anesthetized,  as  their  nerve  supply  is  from  the  lingual. 

THE  FACE 

In  superficial  and  minor  operations  upon  the  soft  parts  of  the 
face  infiltration  anesthesia  of  the  area  involved  is  usually  the  method 


Fig.  157. — Method  of  procedure  for  anesthetizing  area  of  tumor  on  external  nose. 

(Braun.) 

employed ;  and  should  be  preferred  for  such  operations  as  the  removal 
of  moles,  naevi,  cysts,  etc.,  and  for  the  closure  of  superficial  wounds 
or  opening  of  abscesses. 

For  such  lesions  as  epitheliomas,  carbuncles,  etc.,  some  form  of 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  529 

regional  anesthesia  should  be  employed;  this  will  depend  upon  the 
location  of  the  lesion;  if  on  the  nose  and  superficially  situated,  the 
field  is  surrounded  by  a  zone  of  anesthesia  made  well  outside  the 
limits  of  the  growth,  passing  the  needle  down,  and  injecting  into 
the  deep  tissues  at  one  or  more  points,  as  shown  in  Fig.  157. 

In  Fig.  158  the  method  of  anesthetizing  the  upper  lip  and  nose  is 
shown.  This  plan  will  be  found  simple  and  effective  for  the  removal 
of  nsevi,  cysts,  and  superficial  operations,  but  it  is  often  preferable  to 
inject  the  infra-orbital  nerves  in  the  canal  when  the  field  of  operation 
is  limited  to  this  area  (Fig.  164).  For  such  operations  on  the  lower 
lip,  a  point  of  anesthesia  is  established  over  the  midpoint  of  the  chin 
below,  and  the  long  needle  with 
large  syringe  entered  at  this  point; 
with  the  finger  in  the  mouth  as  a 
guide,  it  is  advanced  between  the 


Fig.  158. — Outline  of  points  of  injec-      Fig.  159. — Method  of  procedure  for  anes- 
tion  and  line  of  infiltration  for  anesthet-  thetizing  lower  lip.     (Braun.) 

izing  nose   and  upper  lip.     (Braun.) 

skin  and  mucous  membrane  toward  the  angle  of  the  mouth,  infil- 
trating as  the  needle  is  advanced  with  solution  No.  2  (0.50  per  cent, 
novocain  and  adrenalin) ;  the  needle  is  now  partially  withdrawn  and 
redirected  in  the  opposite  direction  and  the  procedure  repeated  (Fig. 
159).  This  embraces  the  intervening  area  between  two  walls  of 
anesthesia,  which  in  a  few  minutes  diffuse  to  skin  and  mucous 
membrane.  Where  it  is  desired  to  remove  the  submental  or  sub- 
maxillary  glands  in  addition  the  procedure  is  illustrated  below. 

Submaxilliary  and  Submental  Glands.— The  removal  of  these 
groups  of  glands  are  usually  necessary  in  connection  with  malignant 
disease  of  the  lips  and  surrounding  parts  and  is  best  done  in  the 
following  way  which  is  quick,  simple  and  effective.  A  single  skin 


530  LOCAL   ANESTHESIA 

puncture  is  made  at  the  midpoint  of  the  chin  where  an  intradermal 
wheal  is  established  (see  Fig.  160).  A  long  fine  needle  and  large 
syringe  is  now  used  and  entered  through  this  wheal,  the  needle  is 
passed  up  through  the  tissues  of  the  lip  between  the  skin  and  mucous 
membrane  well  to  the  side  of  the  lesion  to  be  removed,  injecting  as  it 
is  advanced  as  far  as  the  vermillion  border  of  the  lip.  The  needle  is 
now  partially  withdrawn  and  redirected  on  the  opposite  side  of  the 
lesion  in  the  same  manner.  These  injections  should  be  freely  made 
and  should  edematize  the  lip  along  their  course.  The  needle  is 
now  almost  completely  withdrawn  and  redirected  backward  under 


Fig.  1 60. 

the  jaw  about  %  inch  internal  to  the  edge  of  the  mandible.  Two 
injections  are  made  on  each  side  along  this  line;  in  the  first  the  needle 
passes  just  beneath  the  skin  injecting  freely  as  it  is  advanced  as  far 
as  the  angle  of  the  jaw;  the  needle  is  now  partially  withdrawn  and 
redirected  in  the  same  line  on  a  deeper  plane  under  the  deep  fascia, 
freely  injecting  as  far  as  the  angle.  The  opposite  side  of  the  jaw  is 
similarly  injected. 

About  2^2  ounces  of  solution  is  needed  for  the  thorough  injec- 
tion of  the  lip  and  submaxillary  region;  after  the  long  needle  has 
once  entered  the  skin  it  is  not  withdrawn  until  the  injections  are 
completed  but  the  syringe  is  detached  from  time  to  time  for  refilling. 

When  properly  done  no  additional  injections  are  needed  during 
the  progress  of  the  operation.  The  lip  is  operated  first  and  when 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


531 


this  is  completed  the  submaxillary  region  should  be  thoroughly 
anesthetized  in  all  directions  by  the  diffusion  of  the  solution.  The 
skin  under  the  jaw  is  best  incised  in  a  horseshoe-like  manner  and 
turned  down  from  the  chin. 

The  same  general  plan  of  procedure  is  followed  for  other  parts 
of  the  face  but  where  the  operation  is  very  extensive  the  branches 
of  the  fifth  nerve  should  be  injected  where  they  leave  the  cranial 
foramina  as  described  in  the  chapter  on  the  Head. 

Superficial  operations  upon  limited  areas  of  the  lower  jaw  may  be 
conveniently  performed  in  a  similar  manner  by  surrounding  the 
area  by  a  wall  of  anesthesia,  carrying  the  infiltration  well  down  to 
the  bone.  Such  an  operative  area  is  outlined  in  Fig.  161,  which 


Fig.  161. — Points  of  injection  and  area  of  infiltration  for  minor  operations  on  inferior 

maxilla.     (Braun.) 

shows  the  points  for  entering  the  long  needle  and  advancing  it  in  the 
deeper  planes.  In  more  extensive  involvement  of  the  bone  this  super- 
ficial infiltration  should  be  supplemented  by  blocking  the  inferior 
dental  nerve  at  the  lingula,  as  referred  to  later.  For  operations 
upon  the  soft  parts  of  the  face,  advantage  may  be  taken  of  the  super- 
ficial position  of  the  infra-orbital  and  mental  nerves  as  they  emerge 
from  their  foramina  and  block  them  at  these  points. 

On  the  face  all  three  branches  of  the  fifth  may  enter  the  field, 
(Fig.  146).  At  the  inner  angle  of  the  lower  lid  we  have  the  infra- 
trochlear  branch  of  the  nasal  and,  approaching  the  ala  of  the  nose, 
branches  from  the  nasal;  over  the  malar  region  branches  of  the  tem- 
poromalar  nerves,  these  from  the  first  division  of  the  fifth;  in  the 
infra-orbital  region,  the  second  division,  and  over  the  side  of  the 
cheek  the  masseteric  and  buccinator  branches  form  the  third 
division,  below  the  line  of  the  mouth  we  have  only  the  third  division, 
but  here  the  field  is  also  supplied  by  ascending  branches  from  the 
superficial  cervical  nerves.  . 

In  operations  in  the  infra-orbital  region,  extending  down  to  and 


532 


LOCAL   ANESTHESIA 


involving  the  bone,  as  for  malignant  disease  so  frequently  met  with  in 
this  region,  the  superior  maxillary  nerve  may  first  be  blocked  by  the 
Matas  intra-orbital  or  one  of  the  lateral  routes.  The  Peuckart 
medial  puncture  of  the  orbit  may  now  be  used  to  control  the  nasal 
nerve  and  its  branches  on  the  inner  side  of  the  lower  lid  and  upper 


Fig.  162. — The  supra-orbital  foramen  is  located  at  the  junction  of  the  inner  and 
middle  thirds  of  the  supra -orbital  margin;  a  line  drawn  from  this  point,  passing  between 
the  two  bicuspids  of  the  upper  and  lower  jaw,  should  pass  over  the  infra-orbital  and  men- 
tal foramina.  (After  Sobotta  and  McMurrich.) 

inner  angle  of  the  face;  if  a  wall  of  anesthesia  is  now  carried  down 
from  the  malar  prominence  to  below  the  line  of  the  mouth,  and  made 
well  down  into  the  subcutaneous  tissues,  it  will  effectively  control 
the  malar,  masseteric,  and  buccinator  nerves. 

If  the  field  is  below  the  line  of  the  mouth  the  inferior  dental  or 
mental  nerve  may  be  blocked  at  the  respective  foramina,  and  the 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


533 


cervical  nerves  controlled  by  a  subcutaneous  line  of  infiltration  over 
the  lower  border  of  the  inferior  maxilla.     Where  two  or  more  branches 


Fig.  163. — Regional  anesthesia  by  way  of  infra-orbital  foramen.     (After  Fischer.) 


Fig.  1 64. —  Resulting  area  of  anesthesia  after  blocking  both  infra-orbital  nerves  at  infra- 
foramen.     (Braun.) 

of  the  fifth  nerve  are  involved  in  the  field  of  operation  it  is  always 
preferable  to  block  the  gasserian  ganglion  when  possible,  but  for 


534 


LOCAL    ANESTHESIA 


various  reasons  this  may  not  be  feasible  we  must  then  have  alterna- 
tive measures  such  as  above. 

In  operations  within  the  mouth  which  are  not  readily  accessible, 
as  in  lesions  far  back  on  the  tongue,  cheek  wall,  pillars  of  the  pharynx, 
etc.,  we  often  slit  the  cheek  back  to  the  ramus  of  the  jaw,  thus  securing 


Post.  sup.  dental  nn. 


Infra-orbital  nn 


Post.  sup.  dental  tin. 


Molars. 

Incisors  and    Bicuspids    Middle  superior  dental  nn. 
canines 

Fig.  165. — Areas  of  nerve  supply  of  maxilla.  Oblique  shading:  anterior  superior 
dental  nerves  (incisor  and  canine  region).  Horizontal  shading:  middle  superior  dental 
nerve  (bicuspid  region);  vertical  shading:  posterior  superior  dental  nerves  (molar 
region).  (After  Fischer.) 

greater  room  and  freer  access  for  work  on  these  deeper  parts.  Such 
incisions  in  the  cheek,  when  properly  closed,  leave  simply  a  linear 
scar. 

For  the  areas  of  distribution  of  the  branches  of  the  fifth  nerve 
to  the  maxillae,  teeth,  gums,  and  hard  palate  see  Figs.  165-168,  while 
the  points  of  emergence  of  the  peripheral  branches  upon  the  face 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


535 


Nasopalatine  notch 
I 


Anastomosis  between  anterior^ 
palatine  and  nasopalatine 
nn. 


Anterior  palatine  n.  — 1®  r**>J — 


Hard  palate. 


Fig.  1 66. — Areas  of  nerve  supply  of  palatine  surface  of  maxilla,  upper  area,  nasopalatine 
nerve.     Lower  area:  anterior  palatine  nerve  (molar  region).     (After  Fischer.) 


Mental  foramen- 


Area  partly  supplied  by  buccinator  n. 

Fig.  167. — Area  of  nerve  supply  of  anterior  section  of  mandible.  Dotted  area :  infe- 
rior dental  nerve.  From  the  mental  foramen  emerges  the  mental  nerve.  The  mucous 
membrane  in  the  molar  region  is  partly  supplied  by  sensory  fibers  of  the  buccinator 
nerve.  (After  Fischer.) 

and  head  is  shown  in  Fig.  146.  A  study  of  this  figure  will  prove 
very  useful  for  operations  upon  the  peripheral  soft  parts.  For  the 
innervation  of  the  mucous  passages  and  accessory  sinuses  a  study  of 
Fig.  196  will  be  found  very  useful. 


536 


LOCAL   ANESTHESIA 


Operations  upon  the  peripheral  ends  of  the  fifth  nerve  can  be 
easily  done,  as  in  resections  for  neuralgia.  The  foramina  are  first 
exposed  by  an  incision  and  an  injection  of  solution  No.  2  made  into 
the  canal,  advancing  the  needle  very  cautiously,  injecting  as  it  is 
advanced  so  as  to  progressively  anesthetize  the  deeper  parts  of  the 
nerve  as  they  are  reached  by  the  needle;  ^  dram  of  solution  used  in 
this  way  will  often  flow  back  into  the  canal  for  some  distance  and 
anesthetize  the  nerve  far  beyond  the  field  of  operation.  After  anes- 
thetizing in  this  way,  the  bony  opening  to  the  canal  can  be  enlarged 
and  the  nerve  reached  further  back  and  excised ;  divulsion  may  also 


Lingual  n. 


Area  supplied-  - 
by   inferior 
dental   and 
lingual  nn. 

Mandibular" 
canal 


Mylohyoid  n. 
Area  supplied  by    Lingual  n. 
inferior  dental  n. 

Fig.  168. — Area  of  nerve  supply  of  lingual  section  of  mandible.  Dotted  area:  in- 
ferior dental  nerve.  The  mylohyoid  nerve  branches  off  at  inferior  dental  foramen. 
(Fischer.) 

be  practised  in  a  limited  way,  but  this  method  of  anesthesia  is  not 
suited  to  severe  traction  upon  the  nerve.  For  this  practice  the  gan- 
glion should  be  blocked. 

Neuralgia  in  general,  but  especially  facial  neuralgia,  was  among 
the  first  conditions  for  which  cocain  was  used,  its  employment  in 
this  way  being  almost  as  old  as  the  discovery  of  cocain,  nevertheless 
there  have  occurred  apparent  cures  from  the  use  of  cocain  alone; 
it  would,  therefore,  seem  not  inadvisable  to  bear  it  in  mind,  as  the 
single  injection  of  medicinal  doses  cannot  possibly  prove  harmful. 
It  must,  however,  further  be  remembered  that  its  use  for  this  pur- 
pose has  nearly  always  been  in  pure  water,  as  well  as  in  the  present 
case  reported.  We  know  aquapuncture  itself  exerts  this  influence;  it 
may,  therefore,  in  this  and  other  cases  not  have  been  the  cocain  at 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  537 

all  which  accomplished  the  cure.  The  case  in  question  is  one  by 
Fitzmiller,  which  is  said  to  have  been  very  severe  and  in  which  all 
other  remedies  had  failed  to  afford  relief  (he  does  not  state  if  aqua- 
puncture  had  been  used) :  The  patient  a  woman,  aged  thirty-two, 
had  suffered  almost  constantly  with  attacks  often  lasting  a  week  in 
length;  a  0.17  per  cent,  watery  solution,  containing  a  few  drops  of 
adrenalin,  was  used;  of  this  solution  a  half  Pravaz  syringeful  was 
injected  at  the  points  of  emergence  of  the  supra-orbital,  infra-orbital, 
mental,  and  occipital  nerves.  It  is  stated  that  immediate  relief 
was  afforded,  the  pain  being  as  if  "blown  away,"  leaving  only  a 
temporary  feeling  of  numbness  in  the  areas  of  distribution  of  the 
nerves.  During  the  next  three  weeks  the  return  of  the  pain  required 
nine  other  injections,  after  which  there  was  no  further  return  when 
last  seen  six  months  later.  This  case  is  merely  cited  to  call  attention 
to  its  possible  use  in  this  way. 

Since  the  introduction  of  novocain  this  agent  has  been  similarly 
used,  either  in  plain  water  or  in  salt  solution  with  adrenalin,  and  the 
relief  obtained  from  these  injections  has  often  been  of  prolonged 
duration.  Its  use  for  this  purpose  is  not  limited  alone  to  facial 
neuralgia,  but  seems  to  be  equally  beneficial  when  used  elsewhere, 
as  for  sciatica,  when  infiltrated  around  this  nerve,  and  for  neuralgia 
of  the  spinal  nerves  as  in  intercostal  neuralgia;  here  the  solution  had 
best  be  used  as  a  paraneural  injection  about  the  nerve-roots,  thor- 
oughly saturating  the  nerve-roots  for  one  or  two  nerves  above  and 
below  the  involved  area ;  in  the  hands  of  the  author  this  method  has 
often  furnished  prolonged  relief. 

Extirpation  of  the  Tongue. — Such  mutilating  operations  are 
rarely  indicated  under  local  anesthesia.  While  possible  in  the  hands 
of  a  skilful  operator,  the  psychical  effect  is  no  doubt  severe  even  upon 
the  most  stoical.  If  the  condition  is  one  of  malignancy,  as  is  usually 
the  case,  and  well  advanced,  local  methods  of  infiltration  are  contra- 
indicated  if  they  in  any  way  encroach  upon  the  diseased  area. 

Well-localized  growths,  when  situated  upon  the  anterior  part  of 
the  tongue,  may  be  quite  satisfactorily  removed  by  creating  a  wall 
of  anesthesia— across  the  tongue,  proximal  to  the  lesion,  and  involv- 
ing its  entire  thickness;  or,  if  the  lesion  is  situated  on  the  side  near 
the  tip,  a  wall  of  infiltration  anesthesia  may  be  carried  down  the  long 
axis  of  the  organ  from  its  tip  to  beyond  the  lesion  and  joined  at  right 
angles  by  a  line  of  infiltration  from  the  side;  or,  if  limited  to  the 
anterior  two-thirds  of  the  organ,  the  area  of  distribution  of  the 
lingual,  this  nerve  may  be  blocked  on  each  side  near  the  lingula. 


538 


LOCAL   ANESTHESIA 


To  remove  the  entire  organ  the  lingual  and  dental  nerves  should 
be  blocked  on  each  side;  this  is  preferable  to  blocking  the  inferior 
maxillary  higher  up  or  to  a  ganglion  injection,  as  the  lingual  receives 
other  nerve-fibers  from  its  communications  after  it  is  given  off  from 
its  parent  trunk. 

As  the  base  of  the  tongue  receives  fibers  from  the  superior  laryn- 
geal  and  glossopharyngeal  to  its  posterior  one-third  both  of  these 
nerves  must  be  dealt  with.  Block  the  superior  laryngeal  on  both 
sides  by  injections  into  the  thyrohyoid  membrane,  as  described  in 
the  chapter  on  the  Neck,  and  carry  a  line  of  subcutaneous  infiltra- 
tion through  the  soft  parts  above  the  hyoid  bone  from  side  to  side, 
to  meet  the  ascending  branches  of  the  superficial  cervical. 

The  glossopharyngeal  is  anesthetized  by  blocking  the  submucous 
tissues  below  and  in  front  of  the  tonsil  toward  the  base  of  the  tongue 
on  each  side;  then,  with  a  finger  in  the  floor  of  the  mouth,  the  long 
needle  is  passed  in  beneath  the  maxilla,  and,  guided  by  the  finger  in 
the  mouth,  the  root  of  the  tongue  on  each  side  is  infiltrated. 

After  a  few  minutes'  delay  anesthesia  should  be  complete  and 
the  inferior  maxilla  divided  at  its  symphysis,  or  an  incision  made 
into  the  mouth  from  beneath  as  preferred. 

The  author  has  never  used  local  or  regional  methods  for  the 

removal  of  tonsillar  tumors,  as,  in 
my  opinion,  this  region  when  the 
seat  of  malignant  disease,  as  most 
of  these  growths  are,  had  best  be 
operated  by  general  anesthesia ;  the 
method  as  outlined  below  is 
quoted  from  Hartel: 

"Operations  for  Tonsillar  Tu- 
mors.— In  the  sensory  innervation 
of  the  tonsils  the  following  nerves 
have  a  share — the  nervus  maxil- 
laris  with  the  nervus  palatinus 
medius,  the  nervus  lingualis  with 


Fig.  169. — Schematic  representation 
of  the  orbital  planes  according  to  Hartel. 
(Hartel.) 


the  rami  isthmi  faucium,  the  nervus  glossopharyngeus  with  the 
ramus  tonsillaris.  While  conduction  anesthesia  can  easily  be  in- 
duced in  the  nervus  maxillaris  and  lingualis,  this  is  impossible  for 
the  trunk  of  the  glossopharyngeus,  because  bone-points  suitable  for 
its  location  are  lacking.  We  must  content  ourselves  with  an  infil- 
tration of  the  peripharyngeal  connective  tissue  situated  laterally 
to  the  tonsils,  and  reach  this  region  from  a  puncture  point  which  is 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  539 

situated  in  the  most  posterior  point  of  the  vestibulum  oris  laterally 
from  the  ligamentum  pterygomandibulare,  which  is  there  palpable; 
from  here  the  tissue  situated  laterally  behind  the  tonsils  is  infiltrated 
in  a  divergent  direction.  Also  from  the  lateral  region  of  the  neck, 
tonsillar  tumors,  which  usually  are  connected  with  collections  of 
glands  in  this  region,  can  easily  be  infiltrated  accompanied  by 
simultaneous  palpation  from  within." 

The  orbits  are  two  quadrilateral  pyramidal  cavities  at  the  upper 
and  outer  parts  of  the  face,  their  bases  directed  forward  and  outward, 
their  apices  backward  and  inward;  their  axes,  passing  through  the 
optic  foramen,  if  continued  backward,  would  meet  over  the  body 
of  the  sphenoid  bone.  The  base  of  this  pyramid  viewed  from  in 
front  presents  somewhat  of  a  rectangular  appearance  (Figs.  169 
and  175),  the  plane  of  this  rectangle  sloping  downward,  backward, 
and  outward  from  the  middle  line  of  the  face. 

The  roof  of  the  orbit,  triangular  in  shape,  presents  a  perfectly 
smooth  concave  surface,  which  slopes  from  the  orbital  margin  first 
upward,  then  downward,  backward,  and  inward. 

The  superior  margin  presents  at  its  inner  extremity  a  depression 
for  the  pulley  of  the  superior  oblique,  sometimes  marked  by  a  spicule 
of  bone.  External  to  this  point  on  the  margin,  at  the  juncture  of 
the  internal  and  middle  thirds,  is  the  supra-orbital  notch  or  foramen. 
On  the  lateral  anterior  surface,  behind  the  orbital  ridge,  is  the 
depression  for  the  lacrimal  gland. 

The  inner  wall,  after  the  lacrimal  groove  is  passed,  presents  a 
smooth,  irregular,  slightly  convex  surface,  directed  almost  directly 
backward.  This  wall  is  extremely  thin  and  paper-like  in  consistence, 
forming  the  delicate  bony  external  wall  of  the  ethmoid  and  sphenoid 
cells. 

At  the  angle  of  the  junction  of  the  roof  and  inner  wall,  in  the 
suture  between  the  frontal  and  the  ethmoid  bones,  are  seen  the 
anterior  and  posterior  ethmoidal  foramina;  the  anterior,  situated 
about  the  midpoint  of  the  depth  of  the  orbital  wall,  transmits  the 
anterior  ethmoidal  vessels  and  nasal  nerve;  the  posterior  foramen 
is  placed  about  midway  between  the  anterior  and  the  orbital  foramen 
and  transmits  the  posterior  ethmoidal  vessels. 

At  the  internal  inferior  angle  is  seen  the  lacrimal  canal. 

The  floor  presents  an  irregular  smooth  surface,  sloping  outward 
and  forward,  slightly  convex  in  its  middle  part,  and  concaved  in 
front  as  it  approaches  the  orbital  margin.  It  is  crossed  from  before, 
backward,  and  outward  by  the  ethmoid  maxillary  suture.  The  bony 


540 


LOCAL   ANESTHESIA 


surface  of  the  floor,  like  the  inner  wall,  is  extremely  thin  and  forms 
the  roof  of  the  antrum  of  Highmore. 

The  outer  wall,  sometimes  deficient  at  the  sphenomalar  articula- 
tion, presents  a  fairly  smooth,  slightly  concave  surface,  which  slopes 
sharply  backward  toward  the  foramen  lacerum  anterius;  on  it  are 
seen  the  orifices  of  the  malar  canals. 

The  sphenomaxillary  fissure  extends  about  two-thirds  of  the 
distance  along  the  angle  of  junction  between  the  external  wall  and 
floor  of  the  orbit.  It  runs  obliquely  backward  and  inward  to  the 
sphenomaxillary  fossa.  This  fissure  is  widest  in  front,  becoming 
narrower  and  somewhat  serpentine  in  direction  behind. 

It  is  formed  above  by  the  lower  border  of  the  orbital  surface  of 
the  great  wing  of  the  sphenoid,  below  and  internally  by  the  external 

Lacrimal 

Frontal 
Fourth 

•Sup.  division  of  third 

Jfasal 

Inf.  division  of  third 
Sixth 
\c  vein 

Fig.  1 70. — Relations  of  structures  passing  through  the  sphenoidal  fissure.     (After  Gray.) 

border  of  the  orbital  surface  of  the  superior  maxilla  and  a  small 
part  of  the  palate  bone. 

At  its  internal  extremity  this  fissure  joins  at  right  angles  with 
the  pterygomaxillary  fissure.  This  fissure  forms  a  means  of  com- 
munication between  four  fossae — the  orbital  in  front,  sphenomaxil- 
lary behind  and  internally,  the  temporal  and  zygomatic  externally 
and  behind.  Through  this  fissure  pass  the  superior  maxillary  nerve 
and  its  orbital  branch,  the  infra-orbital  vessels,  and  ascending 
branches  from  the  sphenopalatine  or  Meckel's  ganglion. 

At  the  apex  of  the  orbital  fossa,  below  and  external  to  the  orbital 
foramen,  is  seen  the  foramen  lacerum  anterius  or  sphenoidal  fissure, 
formed  internally  by  the  body  of  the  sphenoid,  above  and  internally 
by  the  lesser  wing  of  the  sphenoid,  below  and  externally  by  the  greater 
wing  of  the  sphenoid. 

Through  this  fissure  pass  the  third,  fourth,  the  three  divisions  of 
the  ophthalmic  division  of  the  fifth  (lacrimal,  frontal,  and  nasal), 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


541 


and  sixth  nerves,  some  filaments  from  the  cavernous  plexus  of  the 
sympathetic,  the  orbital  branch  of  the  middle  meningeal  artery,  a 


Fig.  171. — Ocular  muscles  viewed  after  removal  of  lateral  wall  of  orbit:  a,  Eyeball; 
b,  optic  nerve;  c,  c',  eyelids;  d,  maxillary  sinus;  e,  pterygoid  plate;/,  foramen  rotundum; 
g,  roof  of  orbit;  h,  frontal  sinus;  i,  supra-orbital  nerve;  k,  septum  orbitale;  i,levator  pal- 
pebrae  superioris;  2,  3,  superior  and  inferior  recti;  4,  4',  portions  of  the  cut  external  rec- 
tus;  5,  internal  rectus;  6,  inferior  oblique;  7,  insertion  of  superior  oblique;  8,  annular  liga- 
ment or  tendon  of  Zinn.  (Testut.) 


Nasal  nerve 


I  I 

Rectus  superior    I 
Annular  tendon   \  \ 


Lachrymal  nerve 

Ciliary  ganglion  and  nerves 


Fig.  172. — Scheme  of  the  ophthalmic  nerve  after  Corning.     (Braun.) 

recurrent  branch  from  the  lacrimal  artery  to  the  dura,  and  the 
ophthalmic  vein. 

The  relative  position  of  these  structures  is  seen  in  Fig.  170. 


542 


LOCAL   ANESTHESIA 


In  making  deep  orbital  injections  for  the  purpose  of  blocking  those 
branches  of  the  trigeminus  which  pass  through  this  fossa  on  their  way 
to  other  parts,  we  should  try  to  select  such  routes  of  puncture  as  lie 
along  smooth  and  regular  bony  surfaces,  using  these  surfaces  as  a 
guide  in  approaching  the  deeper  parts,  and  always  keeping  the  needle- 
point in  close  contact  with  the  bone;  in  this  way,  by  keeping  well 
toward  the  peripheral  limits  of  the  orbit,  we  are  in  the  zone  outside 


Fig.  173. — Base  of  skull  with  cranial  nerves,  from  Arnold.     Needles  a  and  b  same  as  Fig. 
217,  c,  to  nasal  nerve,  d  to  frontal  and  lacrimal  nerves.     (Hartel). 

of  the  eye  and  its  attached  muscles.  This  idea  of  utilizing  the  orbit 
as  a  means  of  approach  to  the  intra-  and  retro-orbital  nerve-trunks 
may  appear  to  the  inexperienced  as  a  hazardous  procedure;  this, 
however,  is  a  misconception,  as  the  puncture  under  proper  technic 
should  be  a  perfectly  innocent  "undertaking,  except  in  the  known 
dangerous  region  of  the  orbit — in  its  axis  or  at  its  apex.  In  extensive 
operations  upon  the  eye,  as  in  enucleation,  these  regions  are  inten- 
tionally invaded.  (Figs.  171,  172  show  the  arrangement  of  the 
nerves  within  the  orbit.) 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


543 


The  recognized  routes  of  orbital  puncture  are: 

1.  Medial  orbital  route,  first  described  by  Peuckart  for  reaching 
the  nasal  nerve  (Figs.  173-181). 

2.  Lateral  orbital  route  of  Braun  for  reaching  the  frontal  and 
lacrimal  branches  of  the  ophthalmic  (Figs.  173,  174). 

3.  Orbital  route,   through  sphenomaxillary  fissure   to  spheno- 
maxillary  fossa,  to  reach  the  second  division  of  the  fifth  at  the 
foramen  rotundum,  the  Matas  route  (Figs.  182-184). 


Fig.  174. — Horizontal  section  of  skull  in  upper  horizontal  plane  seen  from  above. 
Needle  c  is  at  the  ethmoidal  foramina  (nasal  nerve);  needle  d  at  the  superior  orbita; 
fissure  (frontal  and  lacrimal  nerves);  i  and  2,  anterior  and  posterior  ethmoidal  foramina. 
3,  superior  orbital  fissure;  4,  optic  foramen.  (Hartel.) 

The  retrobulbar  methods  of  infiltration  for  bulbar  operations 
— the  methods  of  Seigrist,  Lowenstein,  and  others. 

5.  In  the  method  of  Levy  and  Baudoin  for  reaching  the  oph- 
thalmic division  of  the  first  through  the  orbit,  the  needle  is  entered 
on  the  outer  wall  of  the  orbit  at  the  level  of  the  inferior  extremity  of 
the  external  angular  process  of  the  frontal  bone  and  advanced  back- 
ward and  inward  beneath  the  lacrimal  gland,  hugging  the  bone  to  a 
depth  of  from  3^  to  4  cm. 

Discussing  the  orbit  and  its  various  points  of  puncture,  Hartel 
has  presented  this  subject  with  much  thoroughness  and  detail,  often 


544 


LOCAL    ANESTHESIA 


surpassing  in  his  clearness  of  presentation  original  routes  advocated 
by  others.     For  this  reason  I  quote  him  as  follows: 

"The  puncture  of  the  orbit  from  the  front,  as  Braun  rightly  indi- 
cates, may  be  undertaken  only  under  continuous  contact  with  the 
bone,  in  order  to  avoid  injury  of  the  eye.  But  now  appear  certain 
difficulties,  from  the  fact  that  the  bony  orbital  margin  bordering 
the  orbit  in  front  has  a  shorter  diameter  than  the  cavity  of  the  orbit 
situated  behind  it.  On  this  account  there  exist  in  the  walls  of  the 
orbit  concavities  which  thwart  'bone-feeling.'  Only  in  certain 


Fig.  175.— Orbit  from  in  front  (photo  from  a  skull  with  wide  fissures):  i,  Ant. eth- 
moid, for.;  2,  frontal  notch;  3,  supra-orbital  notch;  4,  post,  ethmoid,  for.;  5,  for.  opticum; 
6,  sup.  orbital  fissure;  7,  lacrimal  fossa;  8,  malar-maxillaris  suture;  9,  infra-orbital  fora- 
men; 10,  infra-orbital  canal;  n,  foramen  rotundum;  12,  planum  pterygoideum;  13,  inf. 
orbital  fissure;  14,  malar-frontal  suture.  (Hartel.) 

places  do  plane  surfaces  variable  in  the  individual  present  themselves 
to  us,  which  we  can  utilize  for  routes  for  injection.  The  walls  of  the 
orbit  are  in  a  high  degree  dependent  on  the  pneumatization  of  the 
adjacent  facial  cavities  (ethmoid  cavity,  frontal  sinus,  sphenoid 
sinus,  antrum  of  Highmore).  This  is  the  cause  of  the  extraordinary 
variability  of  the  orbital  walls.  On  account  of  these  relationships 
' bone-feeling'  as  the  single  guide  of  our  needle  is  often  problematic, 
particularly  as  the  paper-thin  walls  often  do  not  offer  satisfactory 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  545 

resistance.  We  need,  therefore,  here  also  the  adherence  to  certain 
instruction  for  direction  as  well  as  instruction  for  definite  depth. 

"The  deepest  concavities  of  the  orbit  lie  above  behind  the  margo 
supraorbitalis  and  outward  under  it,  while  the  medial  wall  (lamina 
papyracea),  the  lateral  wall  (orbital  surface  of  the  malar  bone  and 
great  wing  of  the  sphenoid  bone),  and  the  medial  part  of  the  inferior 
wall  (orbital  surface  of  the  upper  jaw)  usually  afford  plane  relation- 
ships. We  obtain,  therefore,  a  medial,  a  lateral,  and  an  inferior  plane 
surface  of  the  orbit.  From  the  medial  plane  surface  we  reach  the 
foramina  ethmoidalia,  from  the  lateral  plane  surface  the  fissura 
orbitalis  superior  with  the  entrance  of  the  nervous  .ophthalmicus, 
from  the  inferior  plane  surface  the  nervus  maxillaris  and  the  foramen 
rotundum. 

"Concerning  the  quality  of  the  plane  surfaces,  Table  II,  Nos.  15, 
16,  and  17,  gives  explanation.  According  to  that,  the  medial  plane 
surface  offers  the  most  favorable  relationships  (80  per  cent,  com- 
pletely plane  way;  in  the  other  20  per  cent,  a  very  slight  concavity  or 
convexity  of  the  planum,  not  interfering  with  puncture).  Less 
favorable  relations  are  found  in  the  lateral  and  the  inferior  plane 
surfaces. 

"As  the  concavities  of  the  orbit,  as  we  have  seen,  lie  in  its  anterior 
part  close  behind  the  orbital  margin,  in  every  case  information  con- 
cerning the  quality  of  the  plane  surfaces  is  possible  by  palpation. 
Therefore,  before  the  puncture  we  can  seek  out  the  most  favorable 
place  by  examination,  and,  by  shoving  the  bulbus  to  one  side,  we  can 
carry  the  needle  into  the  depth,  even  if  the  relations  are  not  entirely 
plane,  without  injuring  the  bulb. 

"If  we  now  observe  the  orbital  margin  (Fig.  175)  in  the  choice  of 
our  puncture  point,  its  configuration  in  the  individual  is  so  varied 
that  even  to-day  the  anatomists  are  not  united  concerning  the 
designation  of  the  margins  and  corners.  For  us  it  is  important  to 
note  definite  points  palpable  through  the  skin.  They  are  these :  the 
sutura  malar-maxillaris  on  the  inferior  margin,  the  sutura  malar 
frontalis  above  laterally,  the  lacrimal  fossa,  as  well  as  the  usually 
palpable  incisurae  supra-orbitalis  and  frontalis.  We  compare  the 
orbital  margin  to  an  obliquely  placed  rectangle  (c,  e,  b,f,  Fig.  169), 
whose  corners  are  formed — laterally  above  (b),  by  the  sutura  malar 
maxillaris,  toward  the  median  line;  above  (e)  by  the  incisura  frontalis, 
toward  the  median  line  below  (c)  by  the  lacrimal  fossa,  laterally  below 
(/)  by  the  rounded  orbital  margin.  In  most  cases  three  of  these 
corners  are  palpable.  Now  this  rectangle  lies  diagonally,  so  that  the 

35 


546 


LOCAL   ANESTHESIA 


horizontal  line  drawn  through  the  superior  outer  angle  (6)  (sutura 
malar  maxillaris)  meets  the  opposite  short  side  in  the  middle  (a), 
and  the  horizontal  line,  drawn  from  the  inner  inferior  angle  (c) 
(middle  of  the  lacrimal  fossa) ,  the  middle  of  the  outer  short  side  (d) . 
We  designate  these  two  lines  ab  and  cd  as  superior  and  inferior  hori- 
zontal lines  of  the  orbit,  and  we  shall  find  that  the  horizontal  planes 
passing  through  these  lines  offer  the  following  important  relations 
to  direction  for  the  puncture  of  the  orbit: 

"If  we  observe  the  orbit  exactly  from  the  front,  so  that  our  direc- 
tion of  vision  corresponds  to  the  central  axis  of  the  orbit,  then  we 
perceive  as  the  middle  point  (Fig.  176)  of  the  orbital  infundibulum 


Fig.  176. — Orbit  from  in  front,  same  specimen  as  Fig.  175  with  the  horizontal  planes 

outlined.     (Hartel.) 

the  inferior  wide  part  of  the  fissura  superioris.  It  lies  exactly  be- 
tween the  two  horizontals  of  the  orbit.  In  the  upper  horizontal  plane 
lie,  from  the  outside  toward  the  median  line,  the  upper  part  of  the 
fissura  orbitalis  superioris,  the  foramen  opticum,  the  foramina 
ethmoidalia,  posterior  and  anterior.  In  the  lower  horizontal  plane 
lies  the  foramen  rotundum.  If  we  keep  our  needle  in  the  horizontal 
planes,  then  we  assuredly  avoid  the  puncture  of  the  broad  inferior 
end  of  the  fissura  superioris,  which  contains  the  nerves  of  the  muscles 
of  the  eye  and  large  veins.  On  puncture  in  the  upper  plane  we 
encounter  laterally  the  place  of  entrance  into  the  orbit  of  the  nervi 
frontalis  and  lacrimalis,  medially  the  place  of  entrance  of  the  nasal 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


547 


nerve.  In  this  connection  precaution  is  to  be  observed  only  in  so 
far  as  danger  exists  of  injury  of  the  nervus  opticus  by  going  too  deep. 
In  the  lower  horizontal  plane  we  encounter  the  nervus  maxillaris  and 
its  orbital  branch,  the  temporomalar. 

"Fig.  177  shows  the  orbit  with  bulb,  conjunctival  sac,  palpebral 
fissure  (after  Merkel),  as  well  as  the  horizontals  ab  and  cd  specified  by 
us,  and  the  puncture-points  for  medial  (i)  lateral  (2)  and  inferior 
(3)  orbital  puncture. 


Fig.  177. — Orbit  and  eye,  showing  outlines  or  orbital  margin.  Heavy  circle  shows 
limits  of  the  bulb;  dotted  circle,  limits  of  conjunctival  sac.  a-b,  Upper  horizontal  plane; 
c-d,  lower  horizontal  plane;  i,  median  point  of  puncture  for  injecting  nasal  nerve;  2, 
point  of  puncture  for  injecting  frontal  and  lacrimal  nerves;  3,  point  of  puncture  for 
orbital  injection  of  foramen  rotundum.  (After  Merkel.) 

"If  we  ask  ourselves  how  the  palpebral  fissure  is  related  to  our 
puncture  points,  then  we  must  remember  this,  that  only  the  inner 
angle  of  the  palpebral  fissure  is  a  fixed  point,  while  the  external  angle, 
when  the  eye  is  opened,  moves  upward  several  millimeters.  The 
inner  angle  of  the  palpebral  fissure  lies  in  the  region  of  the  lacrimal 
fossa,  and  the  palpebral  fissure  occurs  varying  in  its  height,  in  any 
case  always  in  the  region  situated  between  the  two  horizontal  planes 
of  the  orbit.  With  the  eye  moderately  opened  the  superior  and  in- 
ferior palpebral  margins  should  correspond  to  the  two  horizontal 
planes.  Therefore,  the  puncture  point  for  the  medial  puncture  as 
well  as  the  puncture  point  for  the  lateral  puncture  lies  above  the 
palpebral  fissure,  as  is  evident  from  Fig.  177. 


548  LOCAL   ANESTHESIA 

"Further,  we  must  bear  in  mind  that  the  central  axes  of  the  two 
orbital  cavities  converge  posteriorly;  consequently,  the  lateral  orbital 
wall  runs  diagonally  from  in  front  backward  toward  the  median  line 
at  an  angle  that  deviates  about  45°  from  the  sagittal.  The  projec- 
tions of  the  straight  lines  drawn  along  the  outer  orbital  walls  meet  in 
the  region  of  the  dorsum  sellae  at  right  angles.  The  medial  orbital 
walls,  on  the  other  hand,  run  approximately  sagittally  and  diverge 
but  little  from  behind  forward. 

"If  we  observe  the  rules  here  mentioned,  then  on  making  the 
orbital  punctures  we  can  assuredly  avoid  an  injury  of  the  bulb  and  of 
the  nervus  opticus.  In  practice  we  displace  the  bulb  with  the  finger 
from  the  point  of  entrance,  and  carry  the  needle  into  the  depth 
between  the  orbital  wall  and  the  finger-tip  that  protects  the  bulb. 
By  this  means  we  keep  the  needle  in  the  region  of  the  horizontal 
planes  mentioned,  and  guard  against  the  point  of  the  needle  entering 
the  region  bounded  by  both  planes  and  from  getting  accidentally 
into  the  point  of  the  orbital  infundibulum.  On  lateral  orbital  punc- 
ture the  axis  of  the  needle  is  at  45°  from  the  sagittal  direction,  on 
medial  and  inferior  puncture  approximately  saggital. 

"If  the  injury  of  the  bulb  and  nervous  opticus  is  thus  technically 
avoidable,  this,  however,  is  not  true  with  equal  certainty  of  the 
vessels  of  the  orbit.  These  are  related  in  detail  as  follows :  On  medial 
orbital  puncture  we  come  in  contact  with  the  terminal  branches  of 
the  ophthalmic  artery,  while  the  trunk  of  the  artery  itself  lies  within 
the  muscular  infundibulum  of  the  orbit  and  is  avoided  by  keeping  in 
contact  with  the  bone.  On  lateral  puncture  we  may  encounter  the 
lacrimal  artery;  on  puncture  of  the  foramen  rotundum  the  anterior 
inf  ra-orbitalis  and  the  communication  of  the  ophthalmic  vein  with  the 
deep  veins  of  the  region  of  the  cheek.  One  may  say  that,  with  cau- 
tious work  and  by  constant  contact  with  the  bone,  the  appearance  of 
hematoma  during  the  orbital  punctures  is  very  rare.  However,  it  is 
not  to  be  excluded,  and  while  these  puncture-hematoma  are  accom- 
panied by  no  danger,  yet  they  cause  temporary  exophthalmus  and 
leave  behind  suffusions  of  the  lids  and  of  the  conjunctiva  which  are 
visible  for  several  days.  For  this  reason  we  should  use  nerve  punc- 
tures in  the  orbit  only  for  the  anesthesia  of  major  procedures. 

"  i.  Medial  Orbital  Puncture  (Peuckart  Route).  Anesthesia  of  the 
Nervi  Ethmoidales  (Figs.  173,  174^,  181). — Where  the  upper  horizon- 
tal plane  touches  the  wall  of  the  orbital  cavity,  the  foramina  eth- 
moidalia  and  the  foramen  opticum  lie  in  one  line.  In  front  the  same 
plane  meets  the  root  of  the  nose.  The  puncture- point,  therefore,  lies 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  549 

on  the  inner  orbital  margin  at  the  height  of  the  root  of  the  nose.  The 
needle  is  entered  in  an  exactly  horizontal  and  approximately  sagittal 
direction  in  constant  contact  with  the  bone.  The  distance  of  the 
foramen  ethmoidale  anterius  from  the  inner  margin  of  the  orbit  amounts, 
according  to  Table  II,  No.  19,  to  from  15  to  22;  on  the  average,  18.5 
mm. ;  therefore,  for  the  anesthesia  of  the  nervus  ethmoidalis  anterius 
(nasal  nerve)  we  will  carry  the  cannula  in  to  the  depth  of  about  2  cm. 
The  nervus  ethmoidalis  anterius  (nasal  nerve)  is  distributed  to  the 
superior  and  anterior  parts  of  the  nasal  mucous  membrane  (compare 
Table  I)  and  to  the  tip  of  the  nose.  In  order  to  strike  the  nervus 
ethmoidalis  posterior,  which  is  distributed  to  the  ethmoidal  cells  and 
the  sphenoidal  cavity,  we  must  carry  the  needle  to  greater  depth. 
The  foramen  ethmoidale  posterius  lies  at  a  distance  from  the  inner 
margin  of  the  orbital  cavity  (see  Table  II,  No.  20)  of  from  29  to  42; 
on  the  average,  34  mm.  This  is  not  so  typically  placed  and  constant 
as  the  foramen  ethmoidale  anterius;  it  is  often  met  with  double. 
Concerning  its  relation  to  the  foramen  optieum  which,  as  we  saw,  is 
situated  in  the  same  plane,  the  following  is  true :  In  a  series  of  cases 
the  medial  orbital  wall  curves  forward  somewhat  in  consequence  of 
pneumatization  of  the  small  wing  of  the  sphenoid  bone,  so  that  behind 
the  foramen  ethmoidale  posterius  the  cannula  strikes  against  bony 
resistance.  But  this  is  the  case  only  in  half  of  the  skulls  (Table  II, 
No.  1 8).  The  distance  of  the  anterior  margin  of  the  foramen  opti- 
eum from  the  inner  margin  of  the  orbital  cavity  amounts  to  37  to  47; 
on  the  average,  40.8  mm.;  in  i  case  it  amounted  only  to  33  mm. 
(compare  Table  II,  No.  21).  If  we  compare  with  this  the  values 
found  for  the  depth  of  the  foramen  ethmoidale  posterius,  then  we  see 
that  on  anesthesia  of  the  nervus  ethmoidalis  posterius  we  come  into 
dangerous  proximity  to  the  optic  nerve.  Therefore,  we  do  well  to 
carry  the  inner  orbital  puncture  not  deeper  than  3  cm.,  and  to  forego 
the  deeper  penetration  to  the  diffusion  of  the  injected  solution. 

"2.  Lateral-  Orbital  Puncture  (Braun  Route).  Anesthesia  of  the 
Nervi  Frontalis  and  Lacrimalis  (Figs.  173,  174,  181). — In  the  upper 
horizontal  plane  of  the  orbit  is  the  lateral  end  of  the  fissure  orbitalis 
superior  with  the  passageway  of  the  frontal  and  lacrimal  nerves.  We 
reach  this  point  by  the  lateral  orbital  puncture  after  Braun,  and  par- 
ticularly by  a  puncture-point  which  is  situated  at  the  upper  lateral 
corner  of  the  orbital  margin  (sutura  malar-frontalis),  or,  with  poor 
development  of  the  lateral  plane  surface,  somewhat  deeper  on  the 
outer  orbital  margin.  If  we  proceed  from  here  with  the  needle  in 
horizontal  position,  and  deviating  from  the  sagittal  direction  about 


55° 

45°  toward  the  median  line  in  constant  contact  with  the  bone  into  the 
depth  of  the  orbit,  we  strike  the  outer  end  of  the  superior  fissure,  and 
on  the  further  side  of  this  in  most  cases  encounter  bone-resistance  on 
the  superior  roof  of  the  orbit  (small  wing  of  the  sphenoid  bone). 
Only  with  a  wide  superior  fissure  does  the  danger  exist  that  the  can- 
nula  without  resistance  may  penetrate  into  the  cranial  cavity.  Ac- 
cording to  Table  II,  No.  22,  we  find  this  relationship  in  14  per  cent,  of 
the  skulls.  The  distance  of  the  outer  end  of  the  superior  fissure  from 
the  lateral  orbital  margin  is  very  variable;  according  to  Table  II,  No. 


Fig.  178. — Left  half  of  sphenoid  bone  seen  from  in  front:  i,  Lesser  wing;  2,  superior 
orbital  fissure;  3,  orbital  surface  of  greater  wing;  4,  foramen  rotundum;  5,  groove  for  sec- 
ond division  of  fifth  nerve;  6,  sharp  bony  edge;  7,  anterior  surface  of  pterygoid  process; 
8,  sphenoid  cells;  9,  vidian  canal.  (Hartel.) 

23,  it  amounts  to  from  27  to  40  mm. ;  on  the  average,  33.5  mm.  This 
relationship  makes  the  lateral  puncture  of  the  superior  orbital  fissure 
somewhat  uncertain,  so  that  I  do  not  believe  that  it  will  ever  come 
into  consideration  for  the  injection  in  cases  of  neuralgia.  For  local 
anesthesia  I  advise  penetration  to  a  maximum  depth  of  about  3  cm. 

"3.  Axial  Puncture  of  the  Foramen  Rotundum.  Orbital  Way  to 
the  Second  Branch  of  the  Trigeminus  (the  Matas  Route,  Author) 
(Figs.  182,  183). — If  we  observe  the  anterior  surface  of  the  sphenoid 
bone,  which  is  turned  toward  the  orbit  (Fig.  178),  then  we  discover 
the  following  details:  the  foramen  opticum,  the  superior  fissure,  and 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


551 


underneath  this  a  surface  shaped  like  an  irregular  triangle,  the  ante- 
rior wall  of  the  process  pterygoideus.  This  surface,  which  we  wish  to 
name  'planum  pterygoideum,'  is  limited  above,  opposite  the  orbital 
surface  of  the  large  wing  of  the  sphenoid  bone,  by  a  clearly  percepti- 
ble sulcus.  This  sulcus  forms  the  path  by  which  the  nervus  maxillaris, 
leaving  the  foramen  rotundum,  reaches  the  sulcus  infra-orbitalis. 
Likewise,  on  the  back  of  the  upper  jaw,  a  groove  lies  opposite  this 
sulcus,  so  that,  by  the  closing  together  of  these  two  half-grooves,  a 
kind  of  canal  is  formed.  At  the  back  end  of  this  canal,  in  the  body 
of  the  sphenoid  bone,  lies  the  foramen  rotundum,  at  its  anterior  end, 
in  the  upper  jaw,  the  canal  infra-orbitalis.  The  lower  outer  margin 
of  the  planum  pterygoideum  forms  a  sharp  bone-corner,  the  limiting 
ridge;  beyond  this  lies  the  fossa  infra temporalis. 


Fig.  179.  Fig.  180. 

Figs.  179  and  180. — Front  and  lateral  views  of  needle  in  position  in  the  orbital  injec- 
tion of  foramen  rotundum.  Front  view  shows  long  axis  of  needle  reaching  upper  inner 
angle  of  the  orbit;  on  lateral  view  it  is  seen  to  reach  upper  margin  of  ear.  (From  a 
cadaveric  specimen.)  (Hartel.) 

"If  on  the  skull  we  carry  a  cannula  from  the  lateral  part  of  the 
inferior  orbital  margin  sagittally  into  the  depth,  then  we  arrive 
through  the  fissura.inferior  at  the  canal  just  mentioned,  between  the 
sphenoid  bone  and  the  upper  jaw,  at  the  end  of  which  canal  lies  the 
foramen  rotundum.  Previously,  however,  the  needle  encounters 
bone-resistance  on  the  planum  pterygoideum  of  the  sphenoid  bone. 
If  we  now  feel  with  the  point  of  the  needle  along  this  resistance  up- 
ward and  medially,  then  we  must  reach  the  foramen  rotundum.  The 
supposition,  by  all  means,  is  that  the  inferior  fissure  is  wide  enough 
and  is  not  too  tortuous.  On  this  account,  the  way  described  is, 
according  to  our  examinations  (Table  II,  No.  24),  accessible  only  in 
89  per  cent,  of  the  skulls;  in  the  rest  of  the  cases  it  is  obstructed  by  the 
inferior  fissure. 

"The  distance  of  the  foramen  rotundum  from  the  inferior  orbital 


552  LOCAL   ANESTHESIA 

margin  amounts  (Table  II,  No.  25)  to  from  39  to  51  mm.;  on  the 
average,  45.4  mm.  For  the  direction  of  the  cannula  the  following  is 
of  value:  the  foramen  rotundum  never  lies  higher  than  the  inferior 
horizontal  plane  of  the  orbit.  The  cannula,  when  carried  into  the 
foramen  rotundum  on  lateral  observation,  points  to  the  superior 
margin  of  the  auricle  (Fig.  179);  on  observation  from  in  front,  it 
points  with  much  shorter  axis  to  the  inner  superior  angle  of  the  orbit, 
the  incisura  frontalis  (Fig.  180). 

"For  the  orbital  puncture  of  the  foramen  rotundum  the  following 
is  important:  The  foramen  is  very  narrow,  and  is  completely  rilled 
by  the  nervus  maxillaris,  hence,  on  introducing  the  cannula  we  have 
to  reckon  with  the  resistance  of  a  tolerably  firm  mass  of  tissue,  so 

Anterior  and  posterior  ethmoidal  foramina 


Fig.  181. — Median  and  lateral  orbital  injections.     (Braun.) 

that  the  injection  demands  a  certain  pressure.  If  this  resistance  is 
lacking  and  the  needle  glides  easily  into  the  depth,  then  we  must 
suppose  that  we  have  gone  beyond  the  foramen  rotundum  into  the 
superior  orbital  fissure.  In  the  living  subject  the  most  important 
guide  for  our  puncture  is  the  subjective  statement  of  the  patient  re- 
garding radiating  pain  in  the  region  of  the  second  branch  of  the  trige- 
minus."  (See  Table  I.) 

The  axial  injection  of  the  foramen  rotundum,  the  Matas  route 
through  the  orbit  and  sphenomaxillary  fissure,  has  been  erroneously 
credited  by  Braun,  Hartel,  and  others  to  Payr;  this,  however,  is  an 
error,  as  the  conception  of  this  method  of  approach  and  its  first  ap- 
plication undoubtedly  belong  to  Prof.  Matas,  who  first  used  it  in  1898, 
and  it  was  published  by  him  in  his  report  on  " Local  and  Regional 
Anesthesia,"  etc.,  to  the  Louisiana  State  Med.  Soc.,  April,  1900. 
Quotations  from  this  report  are  given  later  on. 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


553 


This  successful  application  stimulated  other  efforts  in  this  direc- 
tion, and  much  of  the  work  which  appeared  in  the  few  years  follow- 
ing along  these  lines  undoubtedly  received  the  idea  and  stimulus  from 
this  procedure. 


Fig.  182. — Matas'  intra-orbital  route  to  foramen  rotundum.     (Braun.) 

In  studying  the  orbit,  with  a  view  of  the  application  of  the  various 
methods,  we  see  that  the  foramen  rotundum  is  concealed  from  view 


Fig.  183. — Needle  in  position  in  Matas'  intra-orbital  injection  within  foramen  rotundum. 

(Braun.) 

just  below  the  floor  of  the  orbit,  and  that  if  this  plane  were  used  as  a 
means  of  reaching  it,  the  needle,  if  directed  toward  the  apex  of  the 
orbit  medially  along  the  floor,  would  pass  into  the  superior  orbital 


554 


LOCAL   ANESTHESIA 


fissure,  and  meeting  no  bony  resistance  here  may,  if  advanced  too  far, 
pass  backward  into  the  cranial  cavity.  This  route  is  discussed  by 
Hartel  (Fig.  184). 

This  would  seem  a  more  dangerous  route,  and  not  likely  to  lead  to 
the  foramen  rotundum,  but  above  it. 

The  original  route,  as  advocated  by  Prof.  Matas,  traverses  the  or- 


Fig.  184. — Horizontal  section  of  left  half  of  skull  in  lower  horizontal  orbital  plane, 
seen  from  above,  with  needle  in  foramen  rotundum:  i,  Infra-orbital  sulcus;  2,  zygomati- 
co-maxillary  suture;  2,  infra-orbital  fissure;  4,  foramen  rotundum;  5,  foramen  ovale. 
(Hartel.) 

bit  for  but  a  short  distance,  as  the  needle  soon  passes  out  of  this  cavity 
into  the  sphenomaxillary  fissure  (Figs.  182,  183). 

If  the  sphenomaxillary  fissures  are  observed,  they  will  be  seen  to 
run  at  right  angles  to  each  other  and  about  on  a  horizontal  plane; 
their  axes  if  continued  back  would  meet  over  the  body  of  the  sphenoid 
bone,  and  if  projected  forward  would  emerge  at  the  inferior  external 
angle  of  the  orbit;  also,  that  the  axis  of  this  fissure,  if  raised  to  a 
slightly  elevated  plane,  would  pass  through  the  orbital  foramen  or 
superior  orbital  fissure  at  the  apex  of  the  orbit. 

The  axis  of  the  foramen  rotundum,  if  viewed  from  within  the 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  555 

skull,  passes  downward,  forward,  and  outward,  and  passes  through 
the  sphenomaxillary  fossa,  and  for  a  short  distance  through  the 
sphenomaxillary  fissure,  and  emerge  upon  the  rim  of  the  orbit  just 
internal  to  its  inferior  external  angle,  at  a  distance  of  from  4  to  5  cm., 
varying  somewhat  in  different  skulls. 

It  will  be  seen  from  the  above  that  undoubtedly  the  safest  method, 
as  well  as  the  surest  of  approach  to  the  foramen  rotundum  is  by  the 
Matas  route,  for  if  a  plane  above  this  route  is  taken  the  needle  may 
pass  on  without  resistance  into  the  cranial  cavity,  but  if  the  route  is 
followed  by  passing  through  the  sphenomaxillary  fissure,  the  needle- 
point impinges  upon  the  body  of  the  sphenoid  bone,  on  the  posterior 
surface  of  the  sphenomaxillary  fossa;  and  if  unable  to  enter  the  fora- 
men rotundum  through  insufficient  play  of  the  needle,  due  to  the 
narrowing  of  the  sphenomaxillary  fissure,  it  is  at  least  in  immediate 
contact  with  the  nerve;  but  if,  after  reaching  the  posterior  wall  of  the 
fossa,  the  foramen  is  felt  for,  by  gentle  manipulation  immediately 
around  the  axis  of  the  needle,  the  foramen  may  often  be  entered,  when 
the  needle  may  be  advanced  a  few  millimeters  further  and  the  in- 
jection made. 

The  proof  of  contact  of  the  needle  with  the  nerve  is  recognized 
by  the  radiating  pains  along  the  branches  of  this  nerve,  felt  on  the 
cheek,  in  the  upper  teeth,  and  in  the  nose. 

Having  reached  with  certainty  the  position  of  the  nerve,  2  c.c.  of 
a  2  per  cent,  novocain-adrenalin  solution  are  injected,  or  if  the  point 
of  the  needle  be  less  accurately  placed  the  injection  of  a  slightly 
larger  quantity  of  a  weaker  solution  (i  to  2  drams  of  a  i  per  cent.) 
will  flood  the  sphenomaxillary  fossa  and  reach  the  nerve  and  all  its 
branches.  According  to  the  studies  of  Hartel  the  foramen  rotun- 
dum is  accessible  in  about  89  per  cent,  of  skulls. 

The  following  case  illustrates  the  early  use  of  this  method  by  Prof. 
Matas,  and  is  his  first  report  of  the  use  of  this  route  ("Local  and  Re- 
gional Anesthesia,"  etc.,  Proc.  Louisiana  State  Med.  Soc.,  1900): 

"A  white  man,  laborer,  aged  forty-eight,  addicted  strongly  to  alcohol  for  years  and 
suffering  with  advanced  arteriosclerosis,  was  admitted  to  Ward  7,  Charity  Hospital 
(April  29,  1899),  for  treatment  of  a  recurrent  epithelioma  of  the  palate,  involving  the 
anterior  alveolar  arch  and  both  upper  maxillary  processes.  The  neoplastic  infiltration 
extended  to  the  right  half  of  the  palate  and  along  the  entire  incisor  region  to  the  first 
right  bicuspid;  the  anterior  half  of  the  hard  palate  also  presented  a  large  ovoid  swelling 
caused  by  malignant  periosteal  invasion.  I  decided  that  I  would  try  to  move  the  entire 
hard  palate,  including  both  palatine  processes  of  the  upper  maxillae,  the  floor  of  the  an- 
trum,  and  the  septal  cartilage  of  the  nose.  A  hypodermic  of  morphin,  Y±  8r->  was  given 
twenty  minutes  before  the  operation.  In  order  to  anesthetize  the  maxillaries  and  the 
palate,  the  sphenopalatine  fossae  were  filled  with  a  No.  i  Schleich  solution,  introduced  by 


556  LOCAL   ANESTHESIA 

a  long  needle  through  the  sphenomaxillary  fissures.  The  needle  was  directed  as  closely 
as  possible  through  the  fissure  in  the  right  orbit  toward  the  infra-orbital  nerve  as  it  enters 
the  infra-orbital  canal.  In  this  way  it  was  expected  that  not  only  the  entire  superior 
maxillary  division  of  the  trigeminus  could  be  anesthetized,  but  that  Meckel's  ganglion 
with  its  palatine  branches  would  be  'blocked'  by  the  anesthetic.  In  a  few  minutes  we 
tested  the  sensibility  of  the  cheeks,  lips,  and  alse  of  nose,  and  were  gratified  to  find  the 
entire  cutaneous  distribution  of  the  infra-orbital  had  been  completely  anesthetized  on 
the  corresponding  (right)  side.  Encouraged  by  this  result,  the  left  sphenopalatine  fossa 
and  infra-orbital  nerve  were  treated  in  the  same  manner  with  identical  results.  Fully 
50  minims  of  Schleich's  No.  i  solution,  reinforced  by  25  minims  of  i  per  cent,  cocain,  were 
injected  into  each  sphenopalatine  fossa.  The  nasal  septum,  which  is  supplied  by  the 
nasopalatine  and  the  nasal  branch  of  the  ophthalmic,  was  controlled  by  a  separate  infil- 
tration, a  long  needle  being  introduced  through  the  frenulum  of  the  upper  lip  into  the 
root  of  the  columna  and  septal  cartilage  of  the  nose.  The  anesthesia  of  the  posterior  pal- 
atine nerves  was  also  reinforced  by  direct  infiltration  in  the  palate.  When  the  last 
injection  had  been  completed  the  patient  said  that  his  palate  and  face  felt  entirely 
"numb,"  and  gave  the  impression  of  a  'dead  block  of  flesh'  wedged  in  his  head.  The 
anesthesia  of  the  jaws  was  then  tested  by  extracting  a  perfectly  sound  right  canine  which 
was  firmly  implanted  in  its  socket.  The  patient  was  surprised  when  he  saw  his  tooth, 
saying  he  had  not  felt  the  least  pain  in  its  extraction.  The  upper  lip  was  then  divided 
in  the  median  line  and  detached  from  the  nose  by  two  lateral  incisions,  which  were  car- 
ried along  the  lower  border  of  the  columna  nasi  and  to  the  nasolabial  groove.  The  lips 
were  then  dissected  away  from  the  gums  and  jaws  as  far  back  as  the  tuberosities  of 
the  maxilla?.  The  two  halves  of  the  upper  lip  were  then  reflected  outward,  and  then 
held  out  of  the  way  with  loops  of  strong  silk  which  acted  as  retractors.  A  very  sharp 
McEwen's  chisel  was  then  driven  by  hand  into  the  body  of  the  right  maxilla  on  a 
level  with  the  floor  of  the  nose.  With  a  few  sharp  strokes  of  the  mallet  the  palatine 
process,  including  the  tuberosity,  was  divided,  and  the  antrum  was  exposed;  the 
same  process  was  repeated  on  the  other  side,  and  the  separation  of  the  septum  nasi 
from  the  jaws  completed  the  line  of  osseous  section.  In  this  manner  the  lower  half  oi 
both  upper  jaws  and  the  entire  hard  palate  with  the  attached  growth  were  mobilized 
and  displaced  downward  en  bloc,  the  connections  with  the  soft  palate  being  severed 
with  a  long  pair  of  strong  curved  scissors.  After  the  removal  of  the  palate,  both  antral 
cavities  and  nasal  fossae  were  widely  exposed.  The  bleeding  was  very  profuse  in  the 
last  stage  of  the  operation  when  the  palate  was  being  detached,  the  palatine  arteries 
spurting  vigorously.  A  large  tampon  of  iodoform  gauze,  impregnated  with  compound 
tincture  of  benzoin,  was  immediately  packed  into  the  palatine  region  and  promptly 
arrested  the  hemorrhage.  The  lining  mucosa  of  the  right  antrum  was  subsequently 
removed  in  its  entirety.  During  the  intra-oral  part  of  the  operation  the  patient's  head 
was  kept  low,  in  Rose's  position.  Throughout  the  whole  procedure,  which  lasted  over 
forty  minutes,  the  patient  gave  us  great  assistance  by  spitting  out  clots  and  altering 
the  position  of  the  head  as  we  directed.  He  said  that  while  the  chisel  was  being  used  he 
felt  the  jar  of  the  instrument,  the  detachment  of  the  vomer  gave  him  some  pain,  but 
what  gave  him  more  alarm  than  anything  else  was  the  sight  of  the  blood  that  he  spat 
out." 

"In  this  case  the  preliminary  injection  of  morphin  was  of  decided 
assistance  in  diminishing  psychic  anxiety.  Fully  180  minims  of 
Schleich's  No.  i  (%  of  i  per  cent.)  solution  and  60  minims  of  a  i  per 
cent,  solution  were  used  in  the  operation.  After  the  removal  of  the 
palate  the  lip  was  still  completely  anesthetized,  andthe  facial  (cuta- 
neous) and  intra-oral  (mucous)  sutures  were  introduced  without  pain. 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  557 

The  patient  was  very  much  exhausted  by  the  ordeal  he  had  undergone, 
but,  after  taking  a  good  drink  of  whisky  and  a  hypodermic  of  strych- 
nin, he  sat  up,  and  said  that,  apart  from  the  jarring  of  the  chisel  and 
the  excitement  of  the  operation-,  he  had  suffered  comparatively  little 
pain.  The  pulse  was  no  and  there  was  little  shock." 

The  use  of  any  but  straight  needles  in  making  these  deep  orbital 
punctures  is  to  be  advised  against,  as  cautioned  by  Braun;  however, 
these  are  very  useful  for  retrobulbar  infiltration  according  to  the 
Lowenstein  technic,  but  should  not  be  used  for  other  injections,  and 
in  making  any  deep  injections  it  is  best  to  use  specially  constructed 
needles  and  syringes.  The  needle  should  be  of  small  caliber  and 
strongly  made  and  with  a  short  beveled  point,  combined  with  aids 
for  determining  and  controlling  distance.  Such  an  outfit,  as  designed 
by  Hartel,  is  seen  in  Fig.  238,  and  can  now  be  obtained  from  American 
manufacturers. 

Such  injections,  made  according  to  the  proper  technic,  should  not 
effect  the  innervation  of  the  bulb,  optic  nerve,  ciliary  nerve,  or  its 
ganglion ;  to  reach  these  the  injection  should  be  made  retrobulbar. 

Injection  of  Inferior  Dental  Nerve. — The  following  excellent  de- 
scription of  the  position  of  the  inferior  dental  foramen  and  the  method 
of  making  a  paraneural  injection  here  has  been  taken  from  Fischer. 

This,  one  of  the  most  accessible  of  the  cranial  nerves,  is  not  as 
accurately  reached  as  one  might  suppose,  and  in  the  hands  of  even 
skilful  surgeons,  who  resort  to  this  procedure  but  occasionally,  many 
failures  may  occur.  It  is  far  easier  to  make  an  accurate  injection 
in  contact  with  the  parent  trunk  (third  division  of  the  fifth)  at  the 
base  of  the  skull  than  to  accurately  inject  this  nerve  here,  both  for 
purposes  of  anesthetization  as  well  as  alcoholization  in  cases  of 
neuralgia. 

In  the  one  case  the  end  may  be  obtained  by  using  a  large  amount 
of  anesthetic  fluid,  but  this  as  it  diffuses  in  all  directions  produces 
a  very  unpleasant  sense  of  paralysis  of  the  throat,  which  is  quite 
terrifying  to  some  patients,  particularly  if  it  occurs  during  the  prog- 
ress of  an  operation. 

An  alcohol  injection,  if  too  liberally  made  at  this  point,  may  result 
in  a  more  or  less  prolonged  trismus  through  the  action  of  the  alco- 
hol upon  the  masticatory  muscles. 

The  inferior  dental  or  oblique  mandibular  foramen  in  the  internal 
surface  of  the  ascending  ramus  permits  the  passage  of  the  inferior 
dental  nerve,  which,  with  the  inferior  dental  artery,  passes  forward 
in  the  dental  canal  of  the  mandible  as  far  as  the  mental  foramen, 


558 


LOCAL   ANESTHESIA 


where  it  divides  into  two  terminal  branches,  incisor  and  mental. 
For  the  technic  of  injection  in  the  oblique  foramen  the  relationship 
of  the  body  of  the  jaw  to  the  ascending  ramus  and  that  of  the  muscles 
to  the  foramen  is  of  vital  importance. 

In  adults  the  ascending  ramus  begins  a  little  behind  the  third 
molar,  sometimes  in  an  abruptly  ascending  surface.  At  its  basis, 
which  must  be  regarded  as  resting  upon  the  alveolar  process,  the  as- 
cending ramus,  in  front  view,  shows  an  outer  buccal  anterior  ridge, 
representing  the  last  ascending  portion  of  the  external  oblique  line. 
(See  Figs.  185-187).  About  0.5  cm.  inward  and  backward  of  this 


Sigtnoid  notch 

\    Plerygoid  depression 

Condyloid  process 


Inferior  dental  foramen  ~~^^ 
Internal  oblique  line*. 


'•Angle 


Mylohoid 
groove 


Internal  genital 
tubercles 


Mylohyoid 
ridge 


Fig.  185. — Side  view  of  inner  surface  of  right  half  of  mandible.  The  long  arrow  indi- 
cates the  direction  in  which  the  needle  should  be  pushed  forward  over  the  lingula.  The 
dotted  circle  indicates  the  area  of  injection.  (Fischer.) 

line  runs  a  ridge  bordering  the  lingual  surface,  the  internal  oblique 
line,  which  gradually  loses  itself  in  the  posterior  section  of  the  coro- 
noid  process.  Between  these  two  lines  in  the  bony  surface  is  situated 
a  more  or  less  pronounced  deep  groove,  which  we  might  call  the 
retromolar  fossa  (Fig.  186).  Above  this  fosa  the  mucosa  is  slightly 
depressed,  in  what  might  be  called  the  retromolar  triangle. 

About  the  middle  of  the  internal  surface  portion  of  the  ascending 
ramus  the  large  inferior  dental  or  mandibular  foramen  is  situated, 
extending  downward  and  forward,  at  the  same  time  marking  the 
termination  of  the  mylohyoid  groove  which  ascends  from  below  ante- 
riorly to  above  posteriorly.  The  orifice  of  the  foramen  itself  is  more 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


559 


or  less  protected  anteriorly  by  a  spicule  of  bone  varying  in  size,  the 
mandibular  lingula  (Figs.  185-187). 

This  lingula  may  be  developed  as  a  pointed  plate  of  bone,  or  as  a 
tongue-like  cover,  or  only  as  a  thickened  process  on  the  anterior 
margin.  Sometimes  the  lingula  is  connected  with  the  lower  free 
margin  of  the  orifice  of  the  foramen  by  a  small  spicule  or  bridge. 


Condyloid  process 


Inferior  dental 
foramen 


Mylohyoid  ridge — 


—  Coronoid  process 


Internal  oblique 

line 
External  oblique 

line 

Internal  oblique 
line 


-Menial  foramen 


Fig.  186. — Relationship  of  the  ascending  ramus  to  the  body  of  the  jaw.  The  arrow 
indicates  the  direction  in  which  the  syringe  should  be  advanced  to  the  inferior  dental 
foramen.  (After  Fischer.) 

The  foramen  itself,  in  adults,  is  always  situated  above  the  alveolar 
ridge  and  in  a  horizontal  plane,  about  1.5  cm.  from  the  anterior  ridge 
of  the  jaw  (the  external  oblique  line)  (Figs.  187-189). 

"The  two  halves  of  the  mandible,  when  viewed  from  in  front, 
gradually  diverge  toward  the  angle,  so  that  the  inner  surface  of  the 
angle  with  the  mandibular  foramen  is  inclined  posteriorly  and 
pharyngeally,  and  appears  to  be  entirely  covered  by  the  internal 
oblique  line.  (See  Figs.  186,  187,  190,  101). 


56° 


LOCAL  ANESTHESIA 


"  Position  of  Syringe. — The  line  of  the  body  of  the  mandible  is  not 
horizontally  continuous  in  a  straight  line  to  the  ascending  ramus, 


Coronoid 
Pr, 


——Condyloid  process 


—'Angle 


Mylohyoid  ridge 


Submaxillary 
fossa 


Fig.  187. — Variations  of  the  inferior  dental  foramen  at  different  ages:  A,  Mandible 
of  a  child,  aged  seven  years  (the  needle  should  be  inclined  slightly  downward);  B,  man- 
dible of  a  youth,  aged  eighteen  years;  C,  mandible  of  a  male  adult,  aged  thirty  years. 
The  arrows  indicate  the  direction  of  the  needle.  (After  Fischer.) 

but  presents  a  lateral  bulging  at  the  angle,  so  that  "the  internal  surface 
of  the  ascending  ramus  is  not  parallel  with  the  lingual  surface  of  the 
body  of  the  jaw.  (See  Figs.  186,  190,  191.)  The  ramus  opens  pos- 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  561 

teriorly.  (See  Figs.  188,  189,  190,  191.)  If,  therefore,  the  oblique 
foramen  is  to  be  reached,  we  must  never  advance  posteriorly  parallel 
with  the  teeth  (Figs.  192,  193),  but  with  the  internal  surface  of  the 


Fig.  188. — Front  view  of  position  of  syringe  in  mandibular  anesthesia:  i,  Internal 
oblique  line;  2,  external  oblique  line;  3,  insertion  of  needle  about  i  cm.  above  masticating 
surface  of  molars.  (After  Fischer.) 

ramus,  at  an  acute  angle  to  the  plane  of  the  teeth  (Figs.  188,  192, 
193,  194).     If  the  direction  of  the  ascending  ramus  is  projected  ante- 


Fig.  189. — Position  of  needle  in  mandibular  anesthesia:  i,  External  oblique  line;  2 
internal  oblique  line;  3,  position  of  needle  at  superior  margin  of  lingula;  4,  most  suitable 
length  of  needle  behind  lingula  (a  further  advancement  would  result  in  failure);  6, 
position  of  needle,  i  cm.  above  level  of  masticating  surfaces  of  molars;  7,  lingula;  8 
inferior  dental  foramen.  (After  Fischer.) 

riorly,  the  line  will  meet  with  the  other  side  in  the  canine  region,  be- 
tween the  canine  and  the  bicuspids  (Figs.  188,  189,  192,  193,  194). 

Thus,  in  order  to  reach  the  inferior  dental  foramen  the  syringe  must 

36 


562 


LOCAL   ANESTHESIA 


be  rested  behind  the  canine  on  the  opposite  side.  (See  Figs.  188,  192, 
193,  194.)  The  foramen  in  adults  is  situated  at  a  higher  level  than 
in  children.  The  horizontal  direction  of  the  needle  must,  therefore, 
be  modified  in  children  by  slightly  lowering  it  posteriorly  and  pharyn- 
geally  in  order  to  reach  the  foramen  directly.  (See  Fig.  187,  A,  B,  C). 
"  Character  of  the  Tissues. — The  character  of  the  tissues  encoun- 
tered is  most  favorable  for  injection  in  the  oblique  foramen. 


Angle 


Clique  line 

Line  of  reflection  of 
mucous  membrane 


Body  of  mandible 

Menial  foramen 


Mental  (incisor) 
foramen 


Canine  fossa    Mental  protuberance 

Fig.  190. — Points  of  injection  for  mucous  anesthesia  in  external  surface  of  mandible. 
The  crosses  indicate  points  of  injection;  small  arrows,  direction  of  needle;  two  large 
arrows,  direction  of  needle  for  injection  in  mental  foramen  and  fossa.  On  the  internal 
surface  of  the  ramus  are  marked  the  points  for  injection  at  mandibular  foramen.  (After 
Fischer.) 

"The  temporal  and  external  pterygoid  muscles  are  inserted 
above,  the  internal  pterygoid  below,  the  foramen,  leaving  the  close 
proximity  of  the  foramen  free  from  muscular  fibers.  (See  Fig.  195.) 

"Instead  we  find  considerable  accumulations  of  loose  interstitial 
connective  and  adipose  tissue,  which  readily  absorbs  and  retains  the 
injected  solution.  (See  Fig.  196.) 

"This  cushion  of  tissue  is  situated  about  i  or  2  cm.  above  the  al- 
veolar process. 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 

"Tecknic  of  Injection. — With  the  left  index-finger  the  anterior 
portion  of  the  base  of  the  ascending  ramus  is  palpated,  the  patient's 
mouth  being  opened  widely.  Two  very  marked  bony  ridges  are 
felt  here,  one  anterior  external,  the  external  oblique  line,  and  one  pos- 
terior internal,  the  internal  oblique  line  (Figs.  188,  189,  192,  193). 
Between  these  two  lines  at  the  root  of  the  ascending  ramus  a  shallow 
bony  grove  is  situated,  which  might  be  properly  called  the  retro- 
molar  fossa,  into  which  the  palpating  finger-tip  sinks  (Figs.  188,  192, 
193,  194.)  The  mucous  membrane  is  caved  in  over  this  fossa  in  some- 


Fig.  191. — Lingual  points  of  injection  for  mucous  anesthesia  of  mandible.  Crosses 
indicate  points  of  injection;  arrows,  direction  of  needle;  black  line  of  dashes,  the  angle  of 
the  ramus  to  the  body  of  the  jaw.  (After  Fischer.) 

what  triangular  shape;  Braun,  therefore,  calls  it  the  retromolar 
triangle. 

"The  internal  oblique  line  is  fixed  with  the  finger-nail,  and  the 
needle  inserted  close  to  the  nail  into  the  mucosa  near  to,  yet  not  im- 
mediately at,  the  edge  of  the  bone  (Figs.  188,  192,  193). 

"The  syringe  is  pushed  forward  horizontally  and  posteriorly  from 
the  canine,  on  the  opposite  side  along  the  internal  surface  of  the  man- 
dibular  half  to  be  anesthetized  (Figs.  188,  189,  192,  193,  194). 

"The  needle  should  be  introduced  to  a  depth  of  not  more  than 
from  1.5  to  2  cm.  under  the  mucosa,  lest  it  advance  too  far  beyond 


564 


LOCAL   ANESTHESIA 


the  foramen  and  the  correct  point  for  the  disposition  of  the  solution 
be  missed. 

"The  injecting  solution  is  then  deposited,  beginning  to  inject  soon 
after  insertion  of  the  needle,  in  order  to  anesthetize  the  lingual  nerve 
at  the  same  time  (if  this  be  desirable).  The  bulk  of  the  solution, 
however,  should  be  injected  in  the  mandibular  foramen. 

"Insertion  of  the  Needle. — The  point  of  the  injection  is  selected  so 
that  the  needle  is  introduced  in  the  molar  triangle,  about  i  cm. 


Fig.  192. — Position  of  syringe  for  injection  at  mandibular  foramen:  ix,  External 
oblique  line;  2X,  retromolar  fossa;  3x,  internal  oblique  line;  4,  mandibular  foramen 
behind  lingula;  5,  incorrect  position  of  syringe,  parallel  to  teeth.  (After  Fischer.) 

above  the  level  of  the  masticating  surfaces  of  the  molars  (Figs.  192, 
193,  195,  197);  in  children  and  youthful  persons,  advancing  a  little 
farther  posteriorly  while  slightly  lowering  the  needle ;  in  old  persons, 
slightly  raising  the  long  needle  (Fig.  187). 

"Difficulties. — The  technic  of  this  form  of  injection  offers  some 
difficulties,  which,  after  some  practice  are  easily  overcome;  above 
all,  it  must  be  observed  that  the  insertion  of  the  needle  is  made  not 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


565 


directly  at  the  edge  of  the  bone  in  the  internal  oblique  line,  but  some- 
what lingually  from  the  bone.  Behind  this  internal  ridge  the  bony 
substance  bulges  still  farther  lingually,  running  over  into  the  lingula 
after  having  first  formed  a  second  convex  excrescence  (Figs.  189,  192, 

I93)- 

"After  the  correct  point  of  insertion,  about  i  cm.  above  the  level 
of  the  masticating  surface  of  the  last  molar,  has  been  found  the  ob- 
lique foramen  is  reached,  just  above  the  lingula,  with  the  needle 
(Figs.  189,  192,  193). 


-  -Inferior  denial  nerve 


Lingual  nene-- 


•Inferior  dental  artery 
Section  through  ascend- 
ing ramus 


„  »  -Retromolar  triangle 


^Mucous  covering 
Jnternal  oblique  line 

Mylohyoid  ridge J    XA        \"~ External  oblique  line 

^T^SvX  Point  of  contact  of  syringe 
with  third  molar 

—  Third  molar 


v.  ^Correct  direction 

of  needle 
Direction  of  dental  arch 


Fig.  193. — Horizontal  section  through  ascending  ramus.  Diagram  showing  position 
of  syringe  and  needle:  i,  Eminence  of  internal  oblique  line;  e,  eminence  of  external 
oblique  line.  (After  Fischer.) 

"The  distance  from  the  anterior  margin  of  the  internal  oblique 
line  to  the  posterior  margin  of  the  lingual  is  about  15  mm. 

"During  the  injection  it  is  best,  as  has  been  correctly  emphasized 
by  Williger,  to  rest  the  syringe  barrel  on  the  bicuspids  or  between 
the  canine  and  first  bicuspids  of  the  opposite  side,  thus  securing  a 
certain  support  for  the  syringe  and  an  indication  for  the  correct  level 
for  the  insertion  of  the  needle.  (See  illustrations.) 

"Management  of  the  Needle. — After  insertion  the  needle  is  ad- 
vanced to  the  bone  without  entering  the  peritoneum  (Figs.  192,  193). 
A  certain  touch  is  soon  acquired  as  to  whether  the  needle  is  being  ad- 
vanced in  the  correct  direction,  not  too  far  pharyngeally,  yet  closely 
enough  to  the  bone.  If,  in  case  of  a  very  sharp  angle  of  the  bone, 
the  periosteum  is  found  to  offer  resistance,  even  though  moderately, 


566 


LOCAL   ANESTHESIA 


the  needle  should  not  be  advanced  any  farther,  and  under  no  condi- 
tion use  force,  else  the  needle  bores  into  the  periosteum  of  the  bone 
and  is  sure  to  break.  It  is  best  to  carefully  withdraw  the  needle  for 


Frtnum  labii 
superioris 
ngiva 


Anterior  pillar 
Posterior  pillar 


Tonsil 

Point  of  insertion  of 
needle  in  retromolar 
fossa 


Isthmus 
Tongue 

Cut  portion  of  cheek 
Lower  dental  arch 
Cingiva 

Frenum  labii    inferioris 
Lower  Up 

Points  for  injection  in  mental  fossa 

Fig.  194. — Oral  cavity,  widely  opened.  The  solid  black  line  indicates  the  correct 
position  of  the  syringe  for  mandibular  anesthesia.  The  arrows  at  the  anterior  portion  of 
the  mandible  indicate  the  points  of  insertion  of  the  needle  in  the  reflection  of  mucous 
membrane  for  injection  in  canine  fossa.  (After  Spalteholz.) 


a  short  distance,  and,  after  slightly  altering  its  direction  pharyngeally, 
to  advance  again  posteriorly. 

"The  bone  should  not  be  reached  before  the  needle  has  gone  for 
a  certain  distance  from  the  point  of  introduction  (Figs.  189,  192,  193), 


yet  not  immediately  at  the  internal  oblique  line,  as  has  already  been 
demonstrated. 

"Injection  of  Solution. — The  solution  should  be  emptied  slowly 
and  carefully,  beginning  immediately  upon  insertion  of  the  needle  in 
order  to  anesthetize  simultaneously  the  lingual  nerve  (should  this  be 
desired — Author),  which  descends  in  front  of  the  inferior  dental  nerve 
(Fig.  193).  The  bulk  of  the  solution,  however,  is  deposited  at  the 

External  pterygoid  m. 


•Internal  pterygoid  m. 


Genioglossus  m. — 
Geniohyoid 


Digastric  m.  Mylohyoid  m. 

Fig.  195. — Origins  and  insertions  of  muscles  upon  inner  surface  of  mandible.     (Rauben 

and  Kopsch.) 

oblique  foramen.  Penetration  of  the  muscles  in  this  region  is  out 
of  the  question,  as  has  been  shown  above  (Fig.  195). 

"Neither  is  there  any  danger  of  puncturing  the  artery,  which  pos- 
sesses thick  walls,  is  protected  by  the  lingula,  and  has  enough  space 
to  evade  into  the  loose  surrounding  tissues  or  into  the  depth  of  the 
inferior  dental  canal  (Fig.  193).  The  corresponding  vein  is  arranged 
around  the  artery  in  form  of  an  intricate  plexus  and  is  equally  well 
protected.  The  injection  in  the  left  ramus  offers  somewhat  greater 
difficulties.  While  in  the  right  oblique  foramen  the  retromalar  tri- 
angle is  palpated  with  the  left  hand  and  the  injection  is  made  with 
the  right,  it  is  advisable  to  use  the  left  hand  for  injection  on  the  left 
side,  according  to  Peuckart's  suggestion,  palpating  and  fixing  the  re- 
tromalar triangle  with  the  right. 

"Effect  of  Injection. — About  three  minutes  after  the  injection  the 
patient  perceives  a  slight  tingling  in  the  lip  and  tongue  on  the  in- 
jected side.  The  tingling  is  the  best  indication  as  to  the  correct  exe- 
cution of  the  injection. 

"The  sensation  gradually  increases,  and  a  certain  numbness  of 
the  entire  half  of  the  jaw  ensues.  The  lip  on  the  anesthetized  side 


568 


LOCAL   ANESTHESIA 


depends  slightly,  exhibiting  symptoms  of  partial  paralysis,  and  the 
patient  usually  feels  as  if  it  were  greatly  swollen.  Difficult  degluti- 
tion is  absent  if  the  technic  has  been  executed  correctly.  Its  pres- 
ence indicates  that  the  injection  has  been  too  far  pharyngeally  and 
posteriorly.  The  concomitant  symptoms  persist  for  about  one  hour, 


Occipitofrontal  m. 

Aponeurosis 
Temporal  fascia 


Temporal  m. 


Zygomatic  arch 


Parotid  gland 


Masseter  m 


•External  pterygoid  m. 


ateral  plate  of  ptery- 
goid process 
•Adipose  tissue 


•Internal  pterygoid  m. 
Mandible 


Fig.  196. — Frontal  section  of  temporal  region.  The  solid  black  line  indicate"  the 
aponeurosis,  the  dotted  line  the  periosteum  and  temporal  fascia.  At  the  mandibular 
foramen  a  mass  of  adipose  tissue  is  observed  which  offers  no  resistance  to  the  advance 
of  the  needle.  (After  Merkel.) 


after  which  they  gradually  subside,  the  former  normal  condition 
being  reestablished  after  about  three  hours." 

For  anesthesia  of  the  hard  palate  and  roof  of  the  mouth  advan- 
tage can  be  taken  of  the  points  of  emergence  of  the  palatine  nerves 
upon  the  hard  palate.  (See  Fig.  166.)  These  can  be  easily  reached 
by  injections  over  the  opening  of  the  anterior  and  posterior  palatine 
canals,  the  anterior  just  behind  the  incisor  teeth  in  the  middle  line 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


569 


(nasopalatine  nerve)  and  the  posterior  just  to  the  inner  side  of  the 
last  molar  tooth  (anterior  palatine),  where  the  hard  palate  joins  the 
alveolar  process,  in  each  case  making  the  injections  deep  down  in 
close  contact  with  the  bone. 

In  using  this  method  to  secure  perfect  anesthesia  it  will  be  neces- 
sary to  block  the  anterior  palatine  nerves  on  both  sides,  as  the 
branches  from  each  side  cross  over  beyond  the  middle  line. 

The  tongue  can  be  anesthetized  by  blocking  the  lingual  nerve 

Glossopharyngeal  n.     Internal  carotid  artery 
and  pneumo gastric  n. 

Cervical  ganglion  of  supe- 
rior sympathetic  trunk 


Internal  jugular  vein 
and  glossopharyn- 
geal  n. 


Parotid  fossa 
Posterior  focal  vein 

External  carotid  arter 

Parotid  gland 

Facial  nerve 

Inferior  dental  artery 
and  nerve 

Mandible 
Masseter  m 


A  tlas  with  prevertebral 

fascia 

Rectus  capitis  anlicus 
major  and  longus 
colli  major 


Eypoglossal  n. 


Tonsil 


Internal  pterygoid  m. 

Internal  maxillary  artery  and  vein 

Fig.  197. — Horizontal  section  through  lower  portion  of  oral  cavity.  Relationship  of 
lower  teeth  to  ascending  ramus  and  mandibular  foramen.  The  large  arrow  indicates 
the  correct  position  of  syringe  and  needle  for  mandibular  injection.  (Corning.) 

with  a  paraneural  injection.  This  nerve  lies  quite  superficial  under 
the  mucous  membrane,  where  it  crosses  from  the  ramus  of  the  jaw 
to  the  base  of  the  tongue ;  if  the  tongue  is  drawn  forward  and  to  the 
opposite  side  this  fold  of  mucous  membrane  is  put  upon  the  stretch. 
A  needle  passed  just  under  the  surface  of  the  anterior  edge  of  this  fold 
to  a  depth  not  to  exceed  %  inch,  and  ^  to  i  dram  of  solution  No.  2 
(0.50  per  cent,  novocain)  injected  in  this  position  will  block  the  nerve; 
the  opposite  side  can  be  similarly  treated,  thus  anesthetizing  the 
anterior  two-thirds  of  the  tongue,  the  field  of  distribution  of  the  lin- 
gual, when  resections  or  any  operations  needed  can  be  performed. 


LOCAL   ANESTHESIA 


The  floor  of  the  mouth  receives  nerves  from  other  sources,  and  will 
have  to  be  separately  anesthetized  by  infiltration  beneath  it  or  the 
method  advocated  for  anesthesia  of  the  entire  tongue,  page  537,  may 
be  utilized  in  whole  or  part,  if  the  operative  field  encroaches  upon 
this  region. 

Alcohol  Injection  of  Nerves. — The  alcoholization  of  nerves  for 
the  treatment  of  neuralgia  had  its  beginning  in  experiments  under- 
taken by  Schlosser  in  1900  and  since  elaborated  and  perfected  by 


Fig.  198. — Sensory  innervation  of  the  mucous  passage  of  the  head  and  throat.     (Hasse.) 
Nerves  shown  in  Roman  characters,  branches  of  the  fifth  in  Arabic.     (Hartel.) 

Ostwald,  Levy,  Baudin,  Taptas,  Sicard,  Harris,  Patrick,  Hartel, 
Offerhaus  and  others,  until  now  the  method  has  become  firmly  es- 
tablished and  is  universally  accepted  as  the  safest  and  best  method 
of  treating  that  dreaded  affliction — trigeminal  neuralgia.  Schlosser 
found  that  the  injection  of  sensory  nerves  with  i  to  2  c.c.  of  80  per 
cent,  alcohol  produced  a  burning  pain  of  momentary  duration,  fol- 
lowed after  a  few  minutes  by  numbness  and  anesthesia,  which  in  the 
course  of  a  week  disappeared  and  was  followed  by  a  return  of  tactile 
sensation,  but  the  pain  sense  remained  absent.  Following  these  ex- 
periments Schlosser's  first  report  on  the  treatment  of  neuralgia  ap- 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,   AND    FACE  571 

peared  in  the  "  Transactions  of  the  Heidelberg  Ophthalmologische 
Gesellschaft,"  1903.  Unfortunately  he  does  not  state  very  clearly 
his  technic,  for  the  reason  as  stated,  that  this  method  of  treatment 
had  not  yet  been  given  sufficient  trial  to  determine  its  merits.  Some- 
what later  he  goes  more  into  detail  and  describes  a  transverse  punc- 
ture from  beneath  the  zygoma;  he  also  describes  a  method  for  reach- 
ing the  foramen  ovale  with  a  finger  in  the  mouth  locating  the  ptery- 
goid  process  behind  the  tuber  maxillare.  The  needle  is  entered 
through  the  mouth  and  pushed  through  the  mucous  membrane  under 
the  guidance  of  the  palpating  finger  and  advanced  some  distance 
upward  and  backward  beyond  the  external  pterygoid  plate,  seeking 
out  the  foramen  ovale. 

This  method  originated  by  Schlosser  has  been  elaborated  and 
perfected  by  others  until  now  we  have  a  variety  of  routes  for  reaching 
the  fifth  nerve  and  its  branches.  The  most  approved  of  these  routes 
I  have  presented  in  this  chapter,  any  one  of  which  may  be  used  alike 
for  alcohol  injections  or  for  purposes  of  anesthesia. 

In  the  buccal  method  of  Ostwalt  for  reaching  the  foramen  ovale 
he  enters  the  needle  through  the  mucous  membrane  at  a  point  oppo- 
site the  last  molar  tooth,  and  advances  it  along  the  external  pterygoid 
process  toward  the  foramen  ovale. 

In  the  buccal  route  of  Offerhaus  he  determines  the  position  of 
the  foramen  ovale  from  the  last  molar  tooth  as  representing  approxi- 
mately an  angle  of  130°,  in  which  direction  he  enters  the  needle. 

It  is  possible  that  by  the  intrabuccal  routes  of  Schlosser,  Ostwalt 
and  Offerhaus  the  ganglion  was  often  reached,  but  never  with  the 
same  degree  of  certainty  as  by  the  Hartel  route.  Hartel  uses  prac- 
tically the  same  route,  except  he  adopts  the  more  aseptic  point  of 
puncture  upon  the  cheek,  and  safeguards  the  passage  of  the  needle  in 
the  right  direction  by  advancing  it  at  determined  angles  and  to  a 
definite  depth,  and  from  a  position  certainly  less  trying  and  unpleas- 
ant to  the  patient. 

Harris  Method  for  Injecting  the  Gasserian  Ganglion. — Among  the 
first  to  report  direct  injections  of  the  ganglion  was  Wilfred  Harris  of 
London  (Royal  Soc.  of  Med.  Neurolog.,  Feb.  25,  1909).  He  demon- 
strated the  successful  injection  of  the  ganglion  with  his  technic  by 
using  colored  solutions  upon  the  cadaver.  A  line  is  first  drawn  from 
the  lower  border  of  the  ala  of  the  nose  to  the  incisura  notch  above  the 
lobule  of  the  ear.  To  follow  this  method  accurately  a  dermographic 
pencil  can  be  used  to  line  up  the  side  of  the  head  and  definitely  es- 
tablish the  landmarks.  In  the  majority  of  skulls  the  above  line 


572  LOCAL   ANESTHESIA 

passes  over  the  lower  border  of  the  sigmoid  notch  of  the  ramus  of 
the  jaw. 

The  free  space  on  the  side  of  the  head  through  which  a  needle 
can  be  passed  inward  is  limited  below  by  this  line,  above  by  the 
lower  border  of  the  zygoma  and  in  front  and  behind  by  the  caronoid 
process  and  condyle  respectively.  These  osseous  limits  are  roughly 
outlined.  The  tubercle  at  the  base  of  the  zygoma  is  now  located. 
If  this  is  not  palpable,  it  is  approximately  2.5  cm.  in  front  of  the 
middle  of  the  external  auditory  meatus.  A  vertical  line  at  right 
angles  to  the  zygoma  is  drawn  through  the  tubercle;  this  line  repre- 
sents a  plane  which  if  carried  through  the  skull  will  pass  through  the 
foramen  ovale  at  a  depth  of  4.5  to  6.5  cm.  from  the  surface,  depend- 
ing upon  the  size  and  shape  of  the  skull.  As  the  spine  of  the  sphenoid 
projects  slightly  downward  and  forward  and  may  overhang  the  fora- 
men ovale  the  opening  of  which  is  directed  downward,  forward  and 
outward,  it  is  best  to  enter  the  needle  about  i  cm.  in  front  of  the 
vertical  line  and  just  about  on  a  level  with  the  ala  nasi-incisura  line 
directing  the  needle  slightly  upward  and  backward  at  such  an  angle 
that  it  will  reach  the  foramen  ovale  at  the  recognized  depth.  This 
method  is  a  simple  procedure  and  much  more  easily  executed  than 
the  Hartel  injection  and  finds  some  advantage  when  considered  in 
connection  with  the  Offerhaus  routes  with  which  it  should  be  studied. 
The  objection  the  author  finds  to  it  is  the  greater  danger  of  wound- 
ing the  internal  maxillary  artery  which  lies  usually  along  the  track 
of  the  needle.  But  this  is  a  negligible  factor  and  rarely  happens 
with  the  proper  needle  and  technic.  The  greater  danger  is  within 
the  skull  after  the  foramen  ovale  has  been  entered  when,  if  the  needle 
is  advanced  too  far,  it  may  wound  the  cavernous  sinus  or  internal 
carotid  which  lie  directly  in  the  track  of  the  needle;  it  should  conse- 
quently never  be  advanced  further  than  i  to  1.5  cm.  within  the  skull. 

The  transverse  methods  of  approach  to  the  third  division  of  the 
fifth  nerve  by  Alexander,  Patrick,  Kiliani,  and  others  are  practically 
the  same  with  minor  modifications,  and  are  well  illustrated  by  the 
procedure  of  Braun,  which,  to  the  author,  seems  established  on  some- 
what better  anatomic  lines. 

The  area  on  the  base  of  the  skull  within  which  lie  the  foramen 
rotundum  and  foramen  ovale  is  within  a  very  limited  space,  yet  their 
approach  is  very  often  surrounded  by  many  difficulties,  which  may 
not  be  the  same  in  any  two  skulls,  due  to  the  individual  variations 
in  the  osseous  arrangement  of  the  parts.  For  this  reason  no  method 
of  approach  that  has  yet  been  devised,  or  is  likely  to  be,  will  guide 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  573 

us  to  the  desired  point  with  unerring  accuracy,  and  no  method  of 
computing  these  variations  in  the  position  of  the  basal  foramina  from 
a  study  of  the  variations  of  the  external  configuration  has  been  found 
reliable.  Much  study  has  been  spent  upon  this  subject  and  many 
skulls  measured,  with  a  view  of  obtaining  some  accurate  information 
to  guide  us  in  the  proper  direction.  Many  ingenious  methods  have 
been  devised,  the  more  notable  and  recent  of  these  are  the  Offerhaus 
and  Hartel  routes,  which,  added  to  the  information  previously  pos- 
sessed on  this  subject,  have  placed  our  methods  of  approach  on  a 
more  accurate  footing.  We  are  now  able  in  the  great  majority  of 
cases  to  make  intraneural  and  even  intraganglionic  (gasserian)  in- 
jections, instead  of  contenting  ourselves  with  paraneural  injections, 
which  were  often  the  best  we  were  able  to  accomplish  in  the  past  in 
reaching  the  third  division  of  the  trigeminus. 

The  problem  of  reaching  the  second  division  with  accuracy  was 
solved  by  Matas,  in  1898,  by  the  intra-orbital  puncture  of  the  fora- 
men rotundum,  although  this  has  by  some  writers  been  erroneously 
attributed  to  Payr. 

The  foramen  rotundum  lies  within  the  sphenomaxillary  fossa,  at 
the  point  of  junction  of  the  sphenomaxillary  and  the  pterygomaxil- 
lary  fissures.  The  foramen  ovale,  at  the  base  of  the  skull,  lies  just 
behind  the  zygomatic  fossa  at  the  base  of  the  external  pterygoid  plate. 

Either  foramen  may  be  approached  from  in  front  or  laterally — 
in  the  case  of  the  foramen  rotundum,  by  the  Matas  route  through 
the  orbit,  and  for  the  foramen  ovale  by  several  routes  through  the 
mouth,  or  the  Hartel  route  through  the  cheek.  The  lateral  or  trans- 
verse approach  to  either  foramen  is  from  above  or  below  various 
points  on  the  zygoma  through  the  temporal  or  zygomatic  fossae. 

Viewed  from  below  (Fig.  201)  we  find  the  region  of  the  foramen 
ovale  to  have  the  following  points  worthy  of  note.  Beginning  for- 
ward and  laterally,  on  the  great  wing  of  the  sphenoid  at  the  pterygoid 
ridge,  and  proceeding  downward,  backward,  and  inward  toward  the 
foramen,  we  see  a  slightly  concave  surface  at  the  base  of  the  external 
pterygoid  plate,  the  area  of  attachment  of  the  external  pterygoid 
muscle;  this  surface  is  perfectly  smooth,  and  leads  downward,  back- 
ward, and  inward  over  a  smooth  convex  rim  of  bone  into  the  foramen 
ovale. 

Approaching  the  foramen  from  below  and  in  front,  along  the  ex- 
ternal surface  of  the  external  pterygoid  plate,  we  find  this  surface 
likewise  smooth  and  even  and  leading  downward  and  backward  into 
the  foramen  ovale. 


574 


LOCAL   ANESTHESIA 


The  external  pterygoid  plate,  like  the  other  parts  concerned  here, 
is  subject  to  a  certain  range  of  variations.  Some  of  these,  met  with 
by  Hartel,  are  shown  in  Fig.  199. 

This  information  is  useful  in  the  following  way:  If  the  needle  is 
advanced  from  in  front  through  the  cheek  or  mouth,  and  its  point 
carried  rather  low,  meeting  the  external  pterygoid  plate,  it  must  be 
advanced  upward  and  backward  along  the  smooth  surface,  feeling 


Fig.  199. — External  lamina  of  pterygoid  process  and  foramen  ovale  on  right  side  of 
skull  seen  from  the  side:  a,  The  external  lamina  and  spina  angularis  are  grown  together 
and  form  the  foramen  Civinini;  b-f,  broad  form  of  external  lamina;  g-l,  narrow  form  of 
external  lamina.  Between  the  foramen  ovale  and  external  lamina  can  be1  seen  more  or 
less  of  the  deeper  situated  parts  forming  the  base  of  the  skull  (pterygoid  and  scaphoid 
fossae).  (Hartel.) 

its  way  to  the  foramen;  if  the  point  is  directed  high  up,  and  first 
meets  the  under  surface  of  the  sphenoid  at  the  base  of  the  pterygoid 
process,  it  must  be  advanced  backward  and  inward  over  the  bone, 
and,  as  this  surface  slopes  downward,  backward,  and  inward  as  the 
needle  successively  feels  its  way  backward,  it  must  be  gradually- 
withdrawn  in  following  the  downward  slope  of  the  bone. 

The  posterior  margin  of  the  foramen  is  formed  by  a  sharp  ridge 
of  bone,  which  is  directed  downward,  forward,  and  outward,  running 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  575 

from  behind,  near  the  foramen  spinosum,  forward  and  inward,  to  be 
lost  in  the  pterygoid  fossa.  On  a  plane  just  back  of  the  foramen 
ovale  we  find  the  sharp  irregular  spinous  process  of  the  sphenoid, 
which  gives  attachment  to  the  internal  lateral  ligament  of  the  jaw 
and  tensor  palatine  muscle.  The  foramen  spinosum  is  seen  running 
through  the  spinous  process  for  the  passage  of  the  middle  meningeal 
artery;  it  usually  lies  just  behind  and  external  to  the  foramen  ovale. 

At  the  apex  of  the  petrous  portion  of  the  temporal  bone,  and  inter- 
nal and  behind  the  foramen  ovale,  is  the  foramen  lacerum  medium. 

Slightly  internal  to  the  foramen  spinosum,  and  behind  the  fora- 
men ovale,  is  seen  the  canal  for  the  Eustachian  tube  and  tensor' tym- 
pani  muscle ;  the  anterior  external  boundary  of  this  canal  is  formed  by 
the  short  ridge  of  bone  which  forms  the  posterior  internal  margin  of 
the  foramen  ovale,  consequently  -it  is  seen  that  the  Eustachian  tube 
and  middle  meningeal  artery  lie  on  a  plane  just  posterior  to  the  fora- 
men ovale.  The  posterior  internal  wall  of  the  Eustachian  canal  is 
formed  by  the  hard,  rough,  and  uneven  convex  surface  of  the  petrous 
portion  of  the  temporal  bone.  The  situation  of  the  Eustachian  tube 
just  back  of  the  foramen  ovale  is  of  much  importance.  If  the  point 
of  the  needle  is  advanced  too  far  posteriorly,  and  comes  in  contact 
with  the  rough  and  irregular  surface  bordering  this  tube,  it  should 
be  at  once  recognized  and  withdrawn  and  redirected  more  anteriorly. 
A  puncture  of  the  Eustachian  tube  is  recognized  by  its  producing 
a  sharp  pain  in  the  ear,  and  if  the  solution  is  injected  it  escapes  down- 
ward into  the  pharynx. 

Just  back  of  the  Eustachian  canal,  in  the  petrous  portion  of  the 
temporal  bone,  is  seen  the  carotid  canal,  usually  lying  in  a  line  directly 
back  of  the  foramen  ovale  from  ~y±  to  3^  inch,  the  Eustachian  tube 
lying  between.  Directly  back  of  the  carotid  canal  is  the  jugular 
fossa.  The  internal  jugular  is  formed  within  the  jugular  foramen  by 
a  juncture  of  the  inferior  petrosal  and  lateral  sinuses.  The  three 
nerves — glossopharyngeal,  pneumogastric,  and  spinal  accessory — 
lie  in  the  above  order  in  front  and  to  the  innerside  of  the  jugular 
within  the  foramen. 

The  distance  of  the  carotid  foramen  from  the  foramen  ovale  is, 
according  to  the  measurements  of  Hartel,  minimum,  8  mm.,  maxi- 
mum, 17  mm.,  with  an  average  of  12.7  mm.,  and  from  the  foramen 
ovale  to  the  jugular  foramen  15  to  28  mm.,  with  an  average  of  20  mm. 
(See  Table  II,  N.  40.) 

It  is  seen  from  the  above  that  the  entire  bony  surface  lying  in 
front  and  to  the  sides  of  the  foramen  ovale  is  smooth,  and  even  while 


576 


LOCAL   ANESTHESIA 


the  bony  surface  behind  it  is  rough  and  irregular ;  consequently,  if  the 
needle  as  it  is  advanced  feels  the  smooth  undersurface  of  the  sphenoid 
it  means  we  are  still  within  safe  territory,  and  that  the  needle  must 
be  gradually  insinuated  backward,  but  if  we  are  come  into  contact 
with  the  rough  and  irregular  surface  lying  posteriorly  we  are  on 
dangerous  ground  and  the  needle  must  be  withdrawn  and  reinserted 
further  forward. 

Lateral  to  the  foramen  ovale,  on  its  outer  side,  is  seen  the  eminentia 
articularis,  and  on  its  outer  extremity,  on  the  lower  margin  of  the 


4- 
5 
6 


o 


,, 

Fig.  200.  —  Schematic  representation  of  the  differences  in  size  and  shape  of  the  foramen 
ovale  obtained  from  116  examinations,  shown  in  natural  size.     (Hartel.) 

zygoma  at  its  root,  is  seen  the  articular  tubercle,  which  is  usually  on 
the  same  lateral  plane  as  the  foramen  ovale. 

For  a  further  description  of  the  anatomy.,  of  this  region  1  quote  the 
following  from  Hartel,  who,  in  his  classical  presentation  of  this  sub- 
ject in  the  "Archiv.  fur  Klin,  Chir.,"  vol.  c,  1912,  in  a  discussion  of 
the  various  routes,  with  a  presentation  of  his  own  method,  contributes 
an  exhaustive  study  of  this  region  which  must  remain  for  all  time  as 
a  monumental  contribution  to  the  surgery  of  the  head,  and  through 
whose  kind  permission  I  am  permitted  to  quote  him  in  this  chapter. 
In  conjunction  with  the  description  of  this  region,  see  Fig.  201. 

"The  form  and  size  of  the  foramen  ovale  vary  extraordinarily. 
Scarcely  a  skull  is  found  whose  foramina  ovalia  are  equal  to  each 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


577 


other.  The  shape  varies  from  the  small  longitudinal  slit  to  the  circu- 
lar form;  there  occur  also  transverse,  oval,  as  well  as  occasionally 
roll  and  kidney  forms.  The  length,  on  the  average  6.9  mm.,  varies 


Fig.  201. — Base  of  the  skull,  external  surface.     (After  Gray.) 

between  5  and  n  mm.  (Table  II,  No.  i),  the  breadth  between  2  and 
7.5  mm.,  with  an  average  of  3.7  mm.  (Table  II,  No.  2). 

"The  accompanying  Fig.  200  shows  the  size  relationships  of  the 
foramen  ovale  found  by  us  in  116  examinations.  According  to  this, 
the  way  through  the  foramen  ovale  must  always  stand  open  for  the 


37 


578 


LOCAL   ANESTHESIA 


cannula  (0.8  mm.  thickness);  still,  according  to  my  experience,  a 
breadth  under  3  mm.  means  a  difficulty  in  puncturing.  We  found 
this  unfavorable  breadth  in  8  per  cent,  of  the  skulls  examined  (Table 


Fig.  202. — The  development  of  the  foramen  Civinini from  the  ossification  of  the  Lig. 
pterygospinosum.  (Photo  from  a  specimen  in  the  Anatomical  Collection) :  i,  Foramen 
ovale;  2,  foramen  Civinini.  (Hartel.) 

II,  No.  3).     Occasionally  the  foramen  ovale  is  not  bony  all  the  way 
around,  and  stands  in  open  connection  with  the  foramen  spinosum 


Fig.  203. — Sagittal  section  through  the  foramen  ovale.  The  section  lies  in  a  some- 
what obliquely  placed  vertical  plane  corresponding  to  the  direction  of  the  needle  to  reach 
the  ganglion:  i,  Impressio  trigemini;  2,  petrous  bone;  3,  carotid  canal;  4,  occipital  bone;  5, 
great  wing  of  sphenoid;  6,  planum  infratemporale;  7,  needle  in  foramen  ovale.  (Hartel.) 

or  lacerum  or  both  (Table  II,  No.  3).  On  the  other  hand,  a  multiple 
foramen  ovale,  which  Offerhaus  found  unusually  frequent  (5  per 
cent.),  we  could  not  observe  in  any  case,  nor  are  any  similar  cases 
mentioned  in  the  anatomic  literature  (Poirier,  Testut).  On  the 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  579 

other  hand,  atypical  venous  emissaries  (foramina  innominata,  venosa, 
Vesalii)  are  frequent  in  the  neighborhood  of  the  foramen  ovale. 

"The  entrance  to  the  foramen  ovale  is  overhung  on  the  anterior 
end  by  the  lamina  lateralis  of  the  pterygoid  process;  behind,  by  the 
spina  angularis.  In  cases  of  strong  development  these  ridges  of  bone 
are  united  by  a  ligament  which  many  times  ossifies  (ligamentum 
Civinini  spina  pterygospinosum)  (Fig.  199).  This  ossification  need 
not  present  a  hindrance  to  puncturing.  If  the  foramen  ovale  lies 
medially  from  the  foramen  Civinini,  then  the  transverse  way  (from 
beneath  the  zygomatic  arch)  must  first  go  through  the  foramen  Civ- 
inini in  order  to  reach  the  nervus  mandibularis,  which  in  practice 
must  involve  difficulties.  Likewise  the  way  from  in  front  through 
the  cheek  or  mouth  can  be  obstructed  by  an  ossified  ligamentum 
pterygospinosum  accompanied  by  narrowness  of  the  foramen  ovale. 
However,  we  have  found  this  relationship  only  once  among  134  ex- 
aminations (Table  II,  No.  3),  while  we  observed  the  ossification  it- 
self nine  times  (7  per  cent.).  The  distance  of  the  posterior  margin 
of  the  foramen  ovale  from  the  foramen  spinosum  is  also  subject  to 
great  variation;  it  varies  between  o  and  6  mm.  (Table  II,  No.  4). 
The  shorter  this  distance,  the  greater,  theoretically,  is  the  danger  of 
injuring  the  arteria  meningea  media.  We  avoid  this  danger  in  punc- 
turing as  we  seek  the  foramen  from  before,  always  feeling  our  way 
very  gradually. 

"The  foramen  ovale  presents  really  not  a  hole,  but  a  bone-canal 
of  about  i  cm.  in  length  (Testut  and  Jacob),  which  penetrates  the 
wing  of  the  sphenoid  bone  (at  this  place  about  7  mm.  thick)  in  diag- 
onal direction  in  front  from  below  laterally;  behind,  upward  toward 
the  median  line.  If  we  observe  the  orifice  of  this  canal  from  the 
undersurface  of  the  skull,  then  we  find  on  the  anterior  outer  side  of 
it  and  on  its  long  side  a  smooth  curvature  gradually  passing  over  into 
the  planum  infra temporale,  while  the  posterior  inner  circumference  is 
bounded  by  a  sharp  ridge  which  rises  sharply  posterior  to  the  fissura 
sphenopetrosa,  the  bed  of  the  tuba  Eustachii.  Therefore,  for  a  con- 
venient introduction  of  the  cannula  the  anterior  outer  long  side  offers 
the  best  chances,  for  here  the  needle  glides  over  a  broadly  curved 
bone  surface  and  catches  the  foramen  from  the  broad  side  (Fig.  203, 
diagonal  vertical  section  through  the  left  sphenoid  bone  and  petrous 
portion  of  the  temporal  bone).  In  addition  I  might  remark  that  the 
planum  infratemporale  in  the  cadaver  skull,  with  soft  parts  in  situ, 
always  offers  to  the  puncture  needle  a  completely  smooth  and  hard 
bone  surface,  while  the  vicinity  of  this  planum  posteriorly  and  in- 


580  LOCAL"  ANESTHESIA 

wardly  is  covered  unevenly,  roughly,  by  cartilage  and  fibrous  tissue, 
and,  therefore,  gives  to  the  needle  the  characteristic  feel  of  a  rough, 
grating  resistance.  We  must  come  into  the  foramen  on  a  smooth,  hard, 
bony  way;  if  we  feel  the  grating  unevenness  we  are  wrong,  and  must  re- 
treat forward  and  outward. 

' '  This  deviation  of  the  needle  on  the  inequalities  of  the  pyramid 
of  the  petrous  portion  of  the  temporal  bone,  of  the  foramen  lacerum, 
or  of  the  fossa  pterygoidea  can  easily  occur  if  one  confines  himself 
exclusively  to  the  angle  between  the  lamina  externa  of  the  wing  of 


Fig.  204. — Hartel  method  for  the  injection  of  the  gasserian  ganglion.  Base  of  skull 
seen  from  above  with  the  needle  passing  through  foramen  ovale  to  the  impressio  tri- 
gemini.  (Hartel.) 

sphenoid  and  the  planum  infra temporale.  One  should  consider 
always  that  the  foramen  ovale  is  located  outwardly  from  this  angle, 
and  that  in  many  cases  the  lamina  externa  is  so  small  that  between 
its  posterior  margin  and  the  foramen  ovale  a  considerable  portion  of 
way  still  remains  open,  which  may  be  as  large  as  8  mm.  Figure  199 
shows  some  skull  variations  which  illustrate  this  relation  between  the 
foramen  ovale  and  the  pterygoid  process.  If  one  seeks  to  find  a 
measurable  expression  for  these  relations  by  measuring  the  breadth 
of  the  outer  wing  of  the  sphenoid  bone  at  the  base,  in  other  words, 
the  distance  of  its  anterior  margin  from  the  foramen  ovale,  then  the 
numerical  relations  described  in  Table  II,  No.  5,  result. 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  581 

"The  rule,  therefore,  which  is  to  be  observed  for  the  sense  of  bony 
resistance  from  the  planum  infratemporale  to  the  foramen  ovale  is 
as  follows: 

"One  goes  gradually  from  before  backward,  maintaining  a  posi- 
tion laterally  from  the  lamina  externa,  and  never  deviates  from  the 
smooth,  hard  substratum.  In  so  doing  the  point  of  the  needle  de- 
scribes an  outwardly  convex  curve. 

"Let  us  now  follow  the  way  further  into  the  skull.  For  the  ac- 
curate puncture  of  the  ganglion  Gasseri  we  have  established  the  re- 


Fig.  205. — Same  as  Fig.  204,  seen  from  the  side,  showing  needle  passing  into  foramen 
ovale  between  ascending  ramus  of  lower  jaw  and  maxillary  tubercle.     (Hartel.) 

quirement  of  adherence  to  the  so-called  axis  of  the  trigeminus;  that 
is,  a  straight  line  going  from  the  middle  of  the  impressio  trigemini 
ot  the  petrous  portion  of  the  temporal  bone  through  the  middle  of 
the  foramen  ovale  (Figs.  204,  205).  Only  a  cannula  introduced  into 
the  skull  in  this  direction  avoids  collateral  injuries  of  the  tissues  adja- 
cent to  the  cavum  Meckeli  (Figs.  212,  213),  namely,  of  the  sinus 
cavernosus,  of  the  carotis  interna,  of  the  sinus  petrosus  superior,  and 
of  the  brain.  If,  as  we  have  said  above,  the  foramen  ovale  is  not  a 
simple  hole,  but  forms  a  bone-canal  about  i  cm.  long,  so  we  find  now 
that  the  long  axis  of  this  canal  corresponds  to  this  axis  of  the  trigemi- 
nus; in  other  words,  passes  parallel  to  the  anterior  surface  of  the 
pyramid  of  the  petrous  portion  of  the  temporal  bone  (Fig.  206) ;  if 


582 


LOCAL   ANESTHESIA 


it  should  not  do  this,  and,  for  example,  should  pass  more  steeply 
(Fig.  206,  b),  then  the  cannula  would  penetrate,  not  into  the  ganglion, 


Fig.  206. — Schematic  representation  of  the  trigeminal  axis  and  the  direction  the 
needle  should  take  to  the  gasserian  ganglion :  a,  Normal  type.  The  long  axis  of  the  bony 
canal  of  the  foramen  ovale  and  the  inclination  of  the  petrous  bone  lie  in  the  direction  A, 
B;  b,  occasional  variation.  The  long  axis  of  the  bony  canal  of  the  foramen  ovale  A,  B 
stands  more  steeply  than  the  inclination  of  the  petrosa  C,  D.  (Hartel.) 

but  through  the  dura  into  the  temporal  lobe;  if  it  passes  more  on  a 
level,  then  the  danger  exists  that  the  cannula  from  above,  through 


r 


Fig.  207. — Projection  upon  the  upper  jaw  of  the  different  axes  of  entrance  to  the 
foramen  ovale,  showing  their  variability:  a,  Medium  steep;  b,  flat;  c,  steep;  d,  overflat; 
e,  oversleep.  (Hartel.) 

the  foramen  lacerum,  may  prick  the  carotis  interna.     The  latter  situa- 
tion we  never  found;  the  former,  less  dangerous,  situation,  very 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


583 


seldom  (three  times  in  114  examinations);  and  even  in  these  cases  of 
incongruence  between  the  inclination  of  the  pyramid  of  the  petrous 


Fig.  208. — Projection  of  an  equally  steep  axis  upon  upper  jaws  of  various  height: 
a,  a',  Short  upper  jaw,  axis  appears  steep;  b,  b',  medium  high  upper  jaw,  axis  appears 
medium  steep:  c,  c',  high  upper  jaw,  axis  appears  flat.  (Hartel). 

portion  of  the  temporal  bone  and  the  long  axis  of  the  canal  of  the 
foramen  ovale  it  suffices  practically,  if  the  needle,  coming  from  below 


Fig.  209. — Position  and  size  of  area  of  skin  anesthesia  for  injection  of  gasserian  ganglion. 

(Hartel.) 

outward,  then  upward  and  inward,  traverses  the  canal  of  the  foramen 
ovale  in  diagonal  direction,  and  thereby  arrives  in  the  direction  of  the 
inclination  of  the  petrous  portion  of  the  temporal  bone  (Fig.  206, 
b,  c,  d). 


584 


LOCAL  ANESTHESIA 


Fig.  210. — Hartel  route,  showing  axis  of  needle  to  pupil  of  eye  when  viewed  from  in 
front  and  to  articular  tubercle  at  base  of  zygoma  when  viewed  from  the  side  (photo  from 
a  cadaver.)  (Hartel.) 


Fig.  2 1 1. — The  carotid  region  and  the  chief  structures.  Note  the  relation  of  the 
internal  jugular  vein,  the  common  carotid  artery,  and  the  pneumogastric  nerve. 
(Campbell.) 

"The  question  is  of  importance  as  to  how  deeply  we  may  go  into 
the  foramen  ovale  with  the  needle.     We  must,  therefore,  measure  the 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


585 


distance  between  the  superior  margin  of  the  pyramid  of  the  petrous 
portion  of  the  temporal  bone  and  the  posterior  inferior  margin  of  the 
foramen  ovale,  and  we  find  (Table  II,  No.  6)  a  minimum  of  14  mm., 
a  maximum  of  23  mm.,  and  an  average  of  19  mm.  The  minimum 
(1.4 cm.)  is  the  standard;  if  we  go  deeper,  we  run  the  danger  of  punc- 


Gromt  for  Super.  1a*l<tuJ.& 
i  for  Ant™ 
T. 


Vtpft 


Fig.  212. — Base  of  the  skull,  inner  or  cerebral  surface.     (After  Gray.) 

turing  through  the  chief  trunk  of  the  trigeminus  through  the  cisternae 
of  the  posterior  cranial  fossa  (cisterna  pontis).  This  has  actually 
happened  to  us  in  the  living  subject,  and  emission  of  fluid  resulted. 
One  secures,  if  one  immediately  draws  the  needle  back  somewhat  and 
then  injects  slowly,  a  very  beautiful  and  certain  conduction  anesthesia 


586 


LOCAL   ANESTHESIA 


of  the  chief  trunk  of  the  trigeminus.  This  deep  procedure  is  always 
to  be  warned  against,  for  thereby  one  runs  the  danger  of  prick- 
ing the  sinus  petrosus  superior,  or  of  injecting  the  solution,  instead  of 


superior  sagittal  sinus 


V         anttrior  br   of  middle 
^\   /         meningeal  art. 

ophthalmic  nerve 


termediote  nerve 
il  auditory  art 


jugular  foramen 


\    kieningeal  or.  of  occipital  art. 
\root  of  abducent  nerve 
root  \of  accessory  nerve 


Fig.  213. — The  dura  mater  with  its  arteries  and  sinuses,  the  veins  of  the  orbit,  and  the 
course  of  the  twelve  pairs  of  cerebral  nerves  through  the  dura  mater.  The  le.f  t  orbit  has 
been  opened.  Upon  the  right  the  tentorium  cerebelli  has  been  removed,  the  commence- 
ment of  the  transverse  sinus  opened,  and  the  dura  mater  excised  along  the  emerging 
nerves  and  the  middle  meningeal  artery.  X  Meningeal  nerve  and  anastomosis  with  the 
spinal  nerve;  *X  =  cut  edge  of  tentorium.  (Sobotta  and  McMurrich.) 

into  the  ganglion,  into  the  posterior  cranial  fossa,  which  has  collateral 
manifestations  (vomiting)  as  a  result. 

"If  we  now  follow  the  axis  of  the  trigeminus  already  mentioned, 


THE    HEAD,    SCALP,    CRANIUM,    BRAIN,    AND    FACE 
Lining  membrane  of  sinus 


Dura  mater  lining 
pituitary  fossa 


Internal  carotid, 


Third  nene 

Fourth  nerve 

First  division  of  fifth  nene 


Sixth  nerve 

Fig.  214. — Showing  the  relative  position  of  the  structures  in  the  right  cavernous  sinus, 
viewed  from  behind.     (After  Gray.) 


Fig.  215. — Nerves  of  the  head  (from  Arnold)  seen  from  the  side:  a,  Needle  directed 
along  orbital  route  (Matas)  into  foramen  rotundum;  b,  Hartel  route  to  gasserian  gang- 
lion. (Hartel.) 


588  LOCAL  ANESTHESIA 

then  we  find  that  it  traverses  the  fossa  infratemporalis,  and  passes 
on  exactly  in  the  middle  line  between  the  ascending  branch  of  the 
lower  jaw  and  the  tuber  maxillare.  For  choosing  the  puncture  joint 
it  is  important  to  know  where  the  lateral  projection  of  this  axis  on  the 
upper  jaw  cuts  the  alveolar  margin.  This  point  is  dependent  on  two 
different  factors,  namely:  (i)  On  the  more  or  less  steep  course  of  the 
axis  of  the  trigeminus;  (2)  on  the  situation  of  the  upper  jaw. 

"According  to  Fig.  207,  the  steeper  the  axis  is  the  farther  behind 
the  upper  jaw  it  strikes;  on  the  other  hand,  according  to  Fig.  208,  an 


Fig.  216. — Right  pterygopalatine  fossa,  foramen  rotundum  and  superior  orbital 
fissure  seen  from  behind.  Needle  a  is  passed  from  the  pterygopalatine  fossa  out  of  the 
foramen  rotundum.  Needle  b  is  pushed  in  a  steeper  direction  through  the  inferior 
orbital  fissure  and  impinges  within  the  superior  fissure.  (Hartel.) 

axis  with  equally  steep  course  will  reach  a  more  or  less  high  built 
upper  jaw  farther  forward  or  behind,  and  so  appear  more  level  or 
steeper.  Whatever  the  real  basis  of  this  relation  may  be  in  the  in- 
dividual case,  in  practice  both  amount  to  the  same  thing;  namely, 
that  we  may  not  seek  the  puncture  point  in  an  exactly  designated 
place,  for  example,  at  the  height  of  a  certain  molar  tooth,  but  that 
the  puncture  point  varies  within  certain  limits.  We  may  not  expect 
that  we  may  penetrate  forthwith  into  the  skull  by  any  one  puncture 
point  selected  and  reach  our  mark,  but  we  must  frequently  make 
up  our  minds  to  repeated  puncture.  This  changes  the  puncture 


THE   HEAD,    SCALP,   CRANIUM,   BRAIN,   AND  FACE 


589 


point  until  it  has  reached  the  right  axis,  and  now  without  resistance 
attains  the  cranial  cavity,  a  situation  that  we  have  indicated  above  by 
the  expression  'concentric  puncture.' 


attriculff'tefnpi 
parietal  br.  of  supti 


Orblntlartt  otutt 


Mipraorbttal  nerve 
'fgomanc  bone  X 


'"»X     I  '*'£ 

menial  „„•„         £££  £™l- 

nerve    "'J'"-  X 

Fig.  217. — The  nerves  and  vessels  of  the  face  (fourth  layer,  the  deep  facial  veins). 
The  zygomatic  arch  has  been  removed,  the  temporalis  with  the  mandibular  coronoid 
process  reflected  upward,  the  mandibular  neck  excised,  the  external  ear  cut  off,  and  the 
entire  mandibular  canal  opened  up.  *  =  Anastomosis  between  supratrochlear  and  inf ra- 
trochlear  nerves.  **=  Branches  of  buccinator  nerve  passing  to  mucous  membrane  of 
the  cheek.  +  =  Mylohyoid  nerve.  +  on  the  vein  =  divided  communication  with  ex- 
ternal jugular  vein.  (Sobotta  and  McMurrich.) 

"We  have  now  examined  the  relation  of  the  axis  of  the  trigeminus 
to  the  upper  jaw  in  different  skulls,  and  designate  as  the  'middle  part' 
an  axis  which  strikes  the  upper  alveolar  margin  at  the  height  of  the 
middle  molar  tooth  (Fig.  207,  a).  'Steep'  means  (c)  cutting  point  of 


590 


LOCAL   ANESTHESIA 
12  34 


Fig.  218. — Normal  course  of  the  internal  maxillary  artery  on  the  outer  side  of  the  ext. 
pterygoid  muscle:  i,  Coronoid  process;  2,  temporal  muscle;  3,  deep  ant.  branch  temp, 
art.;  4,  infra-orbital  artery;  5,  post.  sup.  alveolar  art.;  6,  buccinator  art.  and  nerve;  7, 
buccinator  muscle;  8,  superficial  temp,  art.;  9,  internal  maxillary  art.;  10,  masseter 
muscle;  n,  inferior  alveolar  art.  and  nerve;  12,  lingual  nerve;  13,  int.  pterygoid  muscle; 
14,  ext.  pterygoid  muscle.  (After  Poirier.) 


Fig.  219. — Atypical  course  of  the  internal  maxillary  on  the  inner  side  of  the  external 
pterygoid  muscle:  i,  Temporal  muscle  and  coronoid  process;  2,  deep  ant.  temporal 
artery;  3,  infra-orbital  artery;  4,  post.  sup.  alveolar  artery;  5,  buccinator  muscle;  6, 
buccinator  artery;  7,  deep  post,  temporal  artery;  8,  internal  maxillary  artery;  9,  mas- 
seter; 10,  inf.  alveolar  artery  and  nerve;  n,  lingual  nerve;  12,  int.  pterygoid  muscle;  13, 
ext.  pterygoid  muscle.  (After  Poirier.) 

the  axis  with  the  posterior  margin  of  the  alveolar  process,  'over  steep' 
(e)  still  farther  back;  'level'  (6)  means  cutting  point  under  the  process 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE 


591 


of  the  malar  bone  at  the  height  of  the  first  molar  tooth,  'over  level' 
(d)  farther  in  front  of  it.  The  values  found  are  entered  in  Table  II, 
No.  7.  It  follows  from  this  that  the  'middle  part'  axis  is  the  most 
frequent,  and  that  in  go  per  cent,  of  skulls  the  axis  cuts  the  upper  alveo- 
lar margin  in  the  region  of  the  three  upper  molar  teeth  (Fig.  208,  b,  a,  c}. 
We  will,  consequently,  accept  as  a  standard  puncture  point  that  op- 
posite the  second  upper  molar  tooth  (of  course,  outside  on  the  cheek), 
and  if  we  do  not  come  to  the  mark  here  we  will  vary  the  point  on  a 


Fig.  220. — External  lamina  pterygoid  process.  Pterygopalatine  fossa  and  max- 
illary tubercle.  Right  side  of  skull  seen  from  the  side:  a,  Wide  fossa  with  spinous  tuber- 
cle (#);  b,  medium  wide;  c-e,  narrow  fossa;  d,  anterior  pterygoid  spine  (y);  e,  spinous 
tubercle  (x),  and  anterior  pterygoid  spine  (y).  (Hartel.) 

line  parallel  to  the  alveolar  margin,  reaching  back  to  the  ascending 
branch  of  the  lower  jaw  and  forward  into  the  region  of  the  upper  pre- 
molar  teeth  (Fig.  209). 

"Now  that  we  have  established  a  bone-way  for  the  foramen  ovale, 
we  must  consider  the  relations  of  the  soft  parts  which  our  cannula 
has  to  pass  through  from  the  cheek  to  the  ganglion  Gasseri. 

"We  had  chosen  our  puncture  point  in  the  lateral  region  of  the 
cheek,  opposite  the  alveolar  margin  of  the  second  upper  molar  tooth. 
The  point  of  the  cannula  penetrates  the  skin  and  finds  itself  in  Bi- 
chat's  fat  of  the  cheek.  The  finger,  placed  in  the  mouth  of  the  pa- 
tient, feels  the  needle  from  the  mucous  membrane,  and  accompanies 
the  advancing  point  of  the  same  through  the  first  strait  between  the 
margin  of  the  lower  jaw  and  the  tuber  maxillare.  The  finger  main- 


592 


LOCAL    ANESTHESIA 


tains  the  integrity  of  the  mucous  membrane  of  the  vestibulum  oris, 
this  being  accomplished  by  a  curved  motion  of  the  needle  around  the 
buccinator  muscle.  The  needle,  therefore,  goes  between  (medially) 
the  buccinator  muscle  on  the  one  side,  and  the  masseter  muscle, 
lower  jaw,  with  processus  coronoideus  and  temporal  muscle  (laterally) 
on  the  other  side,  through  into  the  fossa  infratemporalis,  and  now 
endeavors  by  perforation  of  the  pterygoideus  muscle  externus,  which 


Fig.    221. — Lateral  route  to  foramen  rotundum.     (Braun.) 

fills  the  entire  fossa,  to  reach  the  planum  infratemporale,  in  connec- 
tion with  which,  as  we  have  seen  above,  finger-feeling  can  be  auxiliary 
only  in  a  portion  of  the  cases.  We  need,  therefore,  other  fixed 
points.  Such  a  point  is  the  depth.  Before  we  stick  the  needle  in  we 
mark  with  the  sliding  catch  a  distance  of  5  to  6  cm. ;  in  case  of  forward 
curving  of  the  cheek  by  a  tumor,  still  more.  We  are  thereby  always 
informed  as  to  the  depth  reached,  and  can  thus  protect  ourselves 
from  gross  errors.  In  the  second  place  we  must  now  consider  a 
direction  discernible  on  inspection  of  the  whole  skull",  and  we  have 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  593 

been  able  by  careful  observation  and  many  examinations  to  estab- 
lish as  essential  for  the  puncture  of  the  foramen  ovale  the  following 
fixed  points : 

"i.  Viewed  exactly  from  the  front  (for  this  determination  of 
direction  one  must,  like  the  designer,  see  with  one  eye  only,  and  pos- 
sibly with  the  aid  of  a  second  cannula  held  freely  before  one),  the 
cannula  introduced  into  the  ganglion  points  to  the  pupil  of  the  eye  on 


Fig.  222. — Lateral  injection  of  second  division  of  fifth  nerve  in  pterygopalatine  fossa. 

(Hartel.) 

the  same  side  (Fig.  210).  If  we  observe  this  rule,  then  we  avoid  de- 
viating outwardly  into  the  fossa  temporalis,  inwardly  into  the  tube 
and  pharynx  region. 

"2.  On  exact  lateral  inspection  the  cannula  points  to  the  tuber- 
culum  articulare  of  the  zygomatic  arch  (Fig.  210).  If  we  do  not 
observe  this  rule,  then  it  may  happen  that  we  come  too  far  forward 
into  the  fossa  pterygopalatina,  or  too  far  back  into  the  region  of  the 
foramen  caroticum  and  of  the  foramen  jugulare;  the  latter  way,  par- 
ticularly— namely,  the  introduction  of  the  needle  into  the  medial 
part  of  the  foramen  jugulare  instead  of  into  the  foramen  ovale — we 

have  several  times  taken  wrongly  on  the  cadaver,  and  the  cannula 

38 


594 


LOCAL   ANESTHESIA 


appeared  at  the  base  of  the  skull,  at  the  place  of  entry  of  the  nervus 
vagus  and  glossopharyngeus  into  the  dura. 

"Viewed  from  below  (with  the  skull  inverted),  the  angle  of  the 
needle  is  seen  in  Fig.  224.  Figure  225  is  a  sagittal  section  of  the 
skull,  and  shows  the  axis  of  the  needle  seen  from  within.  Figure  226 
is  a  skiagraph  of  the  needle  transfixing  the  ganglion.  In  Fig.  227  is 


Fig.  223. — Pterygopalatine  fossa  and  contents,  showing  the  S  form  of  the  maxillary 
nerve  and  the  position  of  the  terminal  branches  of  the  internal  maxillary  artery  beneath 
the  nerve:  i,  Zygomatic  nerve;  2,  infra-orbital  artery;  3,  int.  maxillary  artery;  4,  man- 
dibular  nerve;  5,  maxillary  nerve;  6,  sphenopalatine  ganglion;  7,  ophthalmic  nerve;  8, 
int.  carotid  art.;  9,  gasserian  ganglion.  (After  Testut  and  Jacob.) 


seen  the  angle  and  point  of  crossing  within  the  skull  of  the  axes  of  the 
needle  if  continued  backward  in  bilateral  puncture. 

"The  observance  of  the  rule  given  above  for  the  direction,  as  well 
as  naturally  the  bone-feeling  on  the  planum  infratemporale,  protects 
us  certainly  from  this  error.  The  pterygoid  muscle  is  perforated 
near  its  origin  on  the  pterygoid  process  and  tuber  maxillare;  often 
the  cannula  goes  through  between  the  two  heads  of  origin. 

"Before  we  conduct  the  point  of  the  needle  from  the  fossa  infra- 
temporalis  into  the  foramen  ovale,  we  take  the  precaution  of  slipping 
back  the  sliding  catch  of  the  cannula  1.5  cm.  from  the  skin-puncture 
place,  in  order  thus  to  be  aware  of  the  depth  of  the  further  advance." 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,   AND   FACE 


595 


A  summary  of  the  essential  points  in  making  the  Hartel  puncture 
is  given  by  Hartel  as  follows : 

"  (a)  Puncture  in  the  cheek  at  the  height  of  the  alveolar  margin  of 
the  second  upper  molar  tooth,  establishing  first  on  the  cheek  a  wide 


Fig.  2  24. — Shows  direction  of  needle  in  transfixing  gasserian  ganglion  by  Hartel  route, 
viewed  from  base  of  skull.     (Original  illustration  from  collection  of  Prof.  Matas.) 

area  of  cutaneous  anesthesia,  which  allows  a  variation  of  the  punc- 
ture point  toward  the  front  or  back  according  to  the  principle  of  the 
concentric  puncture. 


Fig.  225 — Shows  axis  of  needle  in  transfixing  gasserian  ganglion  by  Hartel  route, 
seen  from  within  on  sagittal  section  of  skull.  (Original  illustration  from  collection  of 
Prof.  Matas.) 

"  (b}  The  cannula  for  puncture  must  be  0.8  mm.  thin,  10  cm.  long, 
and  be  provided  with  a  flatly  ground  point.  Before  the  puncture 
with  the  puncture-cannula,  the  anticipated  puncture  depth  to  the 


596  LOCAL   ANESTHESIA 

planum  infratemporale  (5  to  6  cm.)  is  marked  on  the  same  with  the 
help  of  an  aseptic  ruler  by  the  sliding  catch  used  on  the  cannula. 

"  (c)  Introduction  of  the  cannula,  accompanied  by  finger-feeling 
between  the  anterior  margin  of  the  ascending  branch  of  the  lower  jaw 
and  the  tuber  maxillare  around  the  buccinator  muscle  to  the  fossa 
infratemporalis. 

"  (d)  Determination  of  the  direction — seen  from  the  front  the  can- 
nula points  exactly  to  the  pupil  of  the  eye  on  the  same  side;  seen  from 
the  side,  to  the  tuberculum  articulare  of  the  zygomatic  arch. 

"(e)  The  puncture  of  the  foramen  ovale  takes  place  under  con- 
tinuing feeling  with  the  hard  and  smooth  surface  of  the  planum  in- 
fratemporale from  the  anterior  exterior  long  side  of  the  foramen. 

"  (/)  After  the  foramen  ovale  is  reached  (relaxing  of  resistance, 
radiating  pain  in  the  area  of  distribution  of  the  third  branch)  the 
sliding  catch  is  shoved  back  1.5  cm.  from  the  puncture  point  of  the 
skin,  and  the  cannula  is  introduced  into  the  foramen  ovale  until  pain 
is  experienced  also  in  the  area  of  distribution  of  the  second  branch. 

"(g)  Attachment  of  the  syringe  containing  2  c.c.  slow  injection 
of  the  solution,  which  must  not  exceed  i  c.c. 

"  (/?)  Immediate  testing  of  the  anesthesia." 

Within  the  middle  fossa  of  the  skull  (Figs.  212,  213)  the  following 
points  are  of  interest:  In  front  is  seen  the  foramen  lacerum  anterius, 
and  immediately  below  this  the  foramen  rotundum,  with  its  axis  di- 
rected downward,  forward,  and  outward  into  the  sphenomaxillary 
fossa.  Posterior  and  external  to  the  foramen  rotundum  is  seen  the 
foramen  ovale. 

The  foramen  spinosum  lies  slightly  external  and  behind  the  plane 
of  the  foramen  ovale  and  its  artery  (middle  meningeal)  as  it  leaves 
the  foramen  curves  outward  hugging  the  bone;  this  vessel  also  is  out 
of  danger  from  the  needle  being  advanced  too  far  within  the  skull. 

At  the  apex  of  the  petrous  portion  of  the  temporal  bone,  where 
this  bone  is  received  into  the  angular  interval,  between  the  basilar 
process  of  the  occipital  and  the  posterior  border  of  the  great  wing  of 
the  sphenoid,  is  seen  the  opening  of  the  internal  carotid  artery  and 
foramen  lacerum  medium. 

The  cavernous  sinus  courses  along  the  inner  margin  of  the  middle 
fossa,  with  the  internal  carotid  artery  lying  along  its  inner  wall,  both, 
internal  and  above  the  foramen  ovale.  The  position  of  the  vessel  at 
this  point  and  its  relation  to  the  sinus  and  orbital  nerves  are  shown  in 
Fig.  214.  Above  and  behind  the  foramen  ovale  is  seen  the  depression 
for  the  gasserian  ganglion.  Above  and  behind  this  depression  on  the 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  597 

superior  margin  of  the  petrous  portion  of  the  temporal  bone  is  seen 
the  groove  for  the  superior  petrosal  sinus. 

The  gasserian  ganglion,  slightly  crescentic  in  shape,  with  its  con- 
vexity forward,  lies  within  the  above  depression  between  the  layers  of 
the  dura  which  receive  it  in  a  slit-  or  pocket-like  interval.  It  is  inti- 
mately attached  to  the  layer  above  but  loosely  to  the  layer  beneath. 
Beneath  it  pass  its  motor  root  and  large  superficial  petrossal  nerve. 
The  large  or  sensory  root  runs  forward  toward  the  ganglion  from  its 
origin  in  the  pons  through  an  oval  opening  in  the  dura  mater,  the 
cavum  Meckeli,  which  communicates  posteriorly  with  the  cisterna 
pontis  of  the  subarachnoid  space,  separated  only  by  a  reticulated 
membrane  the  porus  trigeminus.  As  the  three  branches  of  the  gan- 
glion blend  intimately  with  the  dura  when  leaving  this  space  the  only 
outlet  is  through  the  porus  trigeminus  behind  and  any  injection  when 
too  liberally  made  must  seek  this  outlet  and  reach  the  cysterna  pontis 
and  posterior  fossa  of  the  skull.  As  this  anatomical  condition  is  of 
considerable  importance  it  will  be  dealt  with  more  in  detail  later. 

In  injecting  all  branches  of  the  third  division  of  the  nerve  it  is  only 
necessary  to  reach  or  enter  the  foramen  ovale  but  if  it  is  desired  to 
reach  the  ganglion  or  the  first  or  second  divisions  of  the  nerve  the 
needle  must  be  advanced  considerably  further  or  else  much  larger 
quantities  injected,  but  it  is  much  preferable  to  get  in  direct  contact 
if  not  within  the  part  to  be  injected  as  in  this  way  the  results  are  much 
more  certain  and  accomplished  with  a  smaller  volume  of  solution  and 
this  is  more  particularly  important  when  using  alcohol  as  its  influ- 
ence is  destructive  and  we  should  limit  it  as  much  as  possible  to  the 
exact  part  we  wish  to  affect.  The  lower  edge  of  the  ganglion  lies 
about  Y±  inch  above  the  inner  surface  of  the  skull  and  about  %  inch 
above  the  opening  of  the  foramen  ovale  on  the  undersurface  of  the 
skull,  the  skull  at  this  point  being  about  %  inch  thick.  The  ganglion 
is  about  %  inch  in  its  long  diameter  and  about  ^  inch  thick.  It  lies 
on  the  petrous  portion  of  the  temporal  bone,  its  outer  surface  sloping 
downward,  outward  and  forward  toward  the  foramen  ovale.  The 
first  or  ophthalmic  division,  which  is  directed  forward,  is  given  off 
from  its  upper  edge  and  is  consequently  about  %  mcn  above  the 
opening  of  the  foramina  on  the  undersurface  of  the  skull.  To  effect- 
ively reach  this  branch,  it  is  only  necessary  to  reach  the  ganglion  or 
get  well  within  it,  which  effectively  reaches  all  branches;  consequently, 
it  is  only  necessary  to  advance  the  needle  about  %  inch  from  the 
undersurface  of  the  skull  or  %  inch  within  the  skull.  Once  within 
the  foramen  ovale  an  injection  made  in  sufficient  quantity  will  flow 


598  LOCAL   ANESTHESIA 

upward  and  backward  and  if  in  sufficient  volume  will  effectively 
reach  all  parts.  Once  reached  the  ganglion  is  easily  affected  by  anes- 
thetic solutions,  but  a  few  minims  of  a  0.5  per  cent,  solution  is  suffi- 
cient to  anesthetize  it  and  if  made  from  the  foramen  ovale  ^  dram  of 
0.5  per  cent,  solution  will  probably  reach  it  in  effective  quantity.  In 
the  case  of  an  alcohol  injection  it  is  highly  desirable  to  get  in  close 
contact  with  the  ganglion  and  accomplish  the  desired  effect  with  the 
minimum  quantity  rather  than  to  make  the  injection  too  free  and  have 
it  diffuse  in  all  directions  and  produce  annoying  temporary,  if  not  seri- 
ous, results.  The  various  disturbances  of  vision,  vomiting,  vertigo, 
etc.,  are  accounted  for  in  this  way. 

The  communication  of  the  ganglion  with  the  subarachnoid  space 
through  the  cavum  Meckeli  is  of  considerable  consequence  in  the  deep 
injections  of  the  ganglion,  as  spoken  of  later.  The  anatomy  of  these 
parts,  as  discussed  by  Hartel,  is  as  follows: 

"Let  us  now  consider  the  anatomy  of  the  cavum  Meckeli  and  of 
the  ganglion  Gasseri  (Figs.  173,  213,  215).  The  trunk  of  the  nervus 
trigeminus  rises  in  the  region  of  the  posterior  cranial  fossa  out  of  the 
pons,  next  passes  through  the  wide  cavity  of  the  cysterna  pontis, 
which  is  filled  with  cerebrospinal  fluid,  and  then  enters  between  the 
sinus  petrosus  superior  and  the  superior  margin  of  the  petrous  portion 
of  the  temporal  bone  through  a  wide,  oval  gate  of  the  dura  mater 
(the  porus  trigemini) ,  into  the  cavum  Meckeli  belonging  to  the  middle 
cranial  fossa.  It  has  less  the  form  of  a  compact  nerve-trunk  than 
that  of  a  bundle  of  nerve-fibers,  lying  loosely  together,  which,  as  is 
well  known,  are  covered  only  with  the  pia  mater.  In  the  cavum 
Meckeli  the  nerve  forms  the  area  triangularis,  and  radiates  into  the 
ganglion  semilunare,  which  extends  itself  toward  the  front  along  the 
root  of  the  great  wing  of  the  sphenoid,  and  sends  off  the  three  trunks 
of  the  trigeminus  through  the  fissura  orbitaKs  superior,  the  foramen 
rotundum,  and  ovale. 

"  The  relation  of  the  ganglion  to  the  walls  of  the  cavum  Meckeli, 
which  is  formed  out  of  a  fold  of  the  dura  mater,  is  as  follows :  With 
the  substratum,  the  dural  membrane,  that  serves  at  the  same  time  as 
the  cranial  periosteum,  the  ganglion  is  but  loosely  connected  by 
means  of  loose  connective  tissue;  with  the  superior  dural  wall  on  the 
contrary  it  is  intimately  united.  The  three  trunks  of  the  trigeminus 
leave  the  ganglion  Gasseri  as  compact  nerve-trunks  closely  adherent 
to  the  dura.  Of  course,  the  motor  portion  of  the  trigeminus  does  not 
participate  in  the  formation  of  the  ganglion.  It  takes  its  origin  as 
the  portio  minor  before  the  sensory  portio  major;  it  passes  then 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  599 

on    the  inferior  side  of  the  ganglion,  and  joins  itself  to  the  third 
branch. 

'From  this  situation  of  the  nerves  arises  the  fact  that  the  resist- 
ance to  a  liquid  injected  with  a  syringe  under  pressure  is  least  on  the 
under  side  of  the  ganglion  and  at  the  place  of  the  entrance  of  the 
main  trunk  of  the  trigeminus  into  the  cavum  Meckeli.  Hence,  there 
exists  the  possibility  that  the  injected  fluid  may  soak  through  the 
porous  trigemini  into  the  cysterna  pontis.  On  sudden  injection  of 
staining  solution  in  the  cadaver  this  may  be  observed,  and  outside  of 
the  ganglion  may  be  produced  a  staining  of  all  the  arachnoid  spaces 
of  the  base  of  the  brain.  It  appears  to  me  that  it  may  very  well  be 
possible  that  the  condition  of  sleep  observed  clinically  by  us  and  by 
Heymann,  in  connection  with  an  injection  of  a  copious  quantity  of 
solution  into  the  ganglion  Gasseri,  is  to  be  attributed  to  this  arach- 
noid infiltration. 

"Of  greatest  importance  for  us,  further,  is  the  situation  of  the 
medial  wall  of  the  cavum  Meckeli,  which  forms  the  dividing  wall  of 
the  same  from  the  sinus  cavernosus.  This  medial  wall  is  a  thin, 
translucent,  dural  membrane.  The  first  branch  of  the  trigeminus, 
immediately  after  its  emergence  from  the  ganglion,  turns  into  this 
dural  membrane  with  a  geniculate  bend,  and  fuses  with  it  so  intimately 
that  a  macroscopic  separation  of  the  sinus  wall  from  the  nerve  is 
not  possible.  If  in  anatomic  books  (Fig.  214)  the  nervus  trigeminus 
I,  oculomotorius,  and  abducens  are  represented  as  passing  'in  the 
lateral  wall'  of  the  sinus,  then  this  statement  must  be  supplemented 
thus:  that  the  relation  of  the  two  nerves  of  the  muscles  of  the  eye  to 
the  lateral  wall  is  a  much  looser  one  than  that  of  the  first  branch  of 
the  trigeminus.  If  one  injects  with  a  syringe  into  the  ganglion  Gasseri 
small  quantities  of  solutions  that  are  diffused  with  difficulty,  such  as 
ink  or  tincture  of  iodin,  then  one  obtains  a  beautiful  infiltration  of 
the  ganglion  and  of  the  chief  trunk  of  the  trigeminus,  while  the  sinus 
cavernosus  and  the  cisternae  of  the  arachnoid  membrane  remain  free ; 
on  the  other  hand,  aqueous  solution  of  methylene-blue  is  diffused 
into  the  sinus  as  well  as  into  the  cisternae.  On  the  relation  of  the 
sinus  cavernosus  to  the  cavum  Meckeli,  just  described,  depends  the 
appearance  observed  by  us  at  first  on  too  sudden  injection  of  quantities 
of  solution  exceeding  i  c.c.;  that  is,  an  overlapping  of  the  paralyzing 
effect  of  the  novocain  on  the  nerves  of  the  muscles  of  the  eye,  which 
manifested  itself  either  in  transient  dilation  of  the  pupil  concerned  or 
in  a  likewise  transient  paralysis  of  the  abducens." 

The  distance  between  the  various  points  of  interest  within  the 
skull,  as  measured  by  Hartel,  are  of  interest. 


600  LOCAL   ANESTHESIA 

From  the  superior  margin  of  the  pyramid  of  the  petrous  portion 
of  the  temporal  bone  to  the  posterior-inferior  margin  of  the  foramen 
ovale  he  gives  a  minimum  of  14  mm.,  maximum  of  23  mm.,  with  an 
average  of  19  mm.  (See  Table  II,  No.  6.) 

The  minimum  of  1.4  cm.  is  the  safe  maximum  depth  to  penetrate 
within  the  foramen;  if  a  greater  depth  is  reached,  there  is  danger  of 
puncturing  the  membranes  and  entering  the  cisterna  pontis.  This 
actually  happened  to  Hartel,  with  the  escape  of  cerebrospinal  fluid; 
besides,  there  is  danger  of  wounding  the  superior  petrosal  sinus  or  of 
injecting  the  solution  beyond  into  the  posterior  fossa  of  the  skull. 

The  shape  and  size  of  the  foramen  ovale  vary  considerably  in 
different  skulls,  and  even  on  the  two  sides  of  the  same  skull,  to  such 
an  extent  that  a  study  of  a  large  number  of  skulls  is  necessary  to  draw 
any  positive  conclusion.  A  composite  of  the  whole,  giving  the  aver- 
age condition  and  variations  from  this  average,  must  necessarily  be 
less  in  a  large  number  of  cases  than  measurements  or  studies  made 
upon  any  single  skull. 

The  same  may  be  said  about  the  relative  position  of  the  foramen 
in  relation  to  the  surrounding  parts;  this  variation  of  position,  how- 
ever, is  less  than  that  of  the  size  and  shape  of  the  foramen. 

The  sphenomaxillary  fossa  is  a  small  triangular  space,  situated  be- 
neath the  apex  of  the  orbit  at  the  angle  of  junction  of  the  spheno- 
maxillary and  pterygomaxillary  fissures.  •  Its  posterior  wall  is  formed 
by  the  base  of  the  pterygoid  process  and  body  of  the  sphenoid,  which 
slightly  overhang  it  in  this  position;  its  inner  wall  is  formed  by  the 
vertical  plate  of  the  palate  bone,  which  slightly  overhangs  it  on  the 
inner  side ;  in  front  is  the  middle  portion  of  the  tuber  maxillare. 

Externally,  it  opens  into  the  temporal  and  zygomatic  fossa  through 
the  pterygomaxillary  fissure. 

Above  the  roof  is  partially  deficient,  where  it  communicates  with 
the  apex  of  the  orbit  beneath  the  sphenoid  fissure. 

Five  foramina  open  within  this  fossa;  on  the  posterior  wall  is  the 
foramen  rotundum;  above,  below,  and  internal  to  this  the  vidian,  and 
still  more  inferiorly  and  internally,  the  pterygopalatine;  on  the  inner 
wall  is  the  sphenopalatine  foramen,  by  which  the  fossa  communicates 
with  the  nasal  cavity.  Below  is  the  superior  openings  of  the  pos- 
terior palatine  canal.  This  fossa  contains,  besides  the  superior 
maxillary  nerve  and  its  branches,  Meckel's  ganglion  and  the  termina- 
tion of  the  internal  maxillary  artery.  It  will  be  seen,  from  a  study 
of  the  above  and  the  use  of  a  needle  on  the  skull,  that  the  transverse 
puncture  made  from  below  the  zygomatic  arch  may,  if  the  point  of  the 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  6oi 

needle  is  directed  too  high  and  advanced  too  far,  enter  the  apex  of  the 
orbit  and  transfix  the  structures  passing  through  the  sphenoid  fissure 
(Fig.  2 1 6) ,  or  may,  if  advanced  sufficiently  far,  enter  the  orbital  fora- 
men; and,  if  directed  more  horizontally  and  advanced  too  far,  may 
enter  the  nasal  fossa  through  the  sphenopalatine  canal. 

This  last  fossa  may  even  be  entered  from  above  the  zygoma,  but 
from  this  angle  it  would  be  impossible  to  enter  the  orbit.  For  this 
reason  some  operators  prefer  the  transverse  route  above  the  zygoma 
instead  of  below  it. 

INTERNAL  MAXILLARY  ARTERY     (Fig.  217.) 

The  larger  of  the  two  terminal  branches  of  the  external  carotid 
is  given  off  at  about  the  level  of  the  lower  extremity  of  the  lobule  of 
the  ear,  at  its  origin  embedded  within  the  substance  of  the  parotid 
gland.  It  first  runs  inward,  at  right  angles  to  its  point  of  origin,  to 
the  inner  side  of  the  neck  of  the  condyle  of  the  lower  jaw,  in  this  its 
maxillary  portion  lying  between  the  ramus  of  the  jaw  and  the  internal 
lateral  ligament.  As  it  passes  opposite  the  sigmoid  notch  it  lies 
usually  a  little  above  its  lower  border,  but  occasionally  as  high  as  i 
cm.  below  the  inferior  border  of  the  zygoma.  In  some  few  cases  the 
artery  may  lie  below  the  tendon  of  the  external  pterygoid,  and,  in 
crossing  inward  from  this  position,  may  be  in  danger  of  being  wounded 
(Figs.  218,  219)  when  approaching  the  foramen  ovale  from  below 
and  in  front,  as  in  the  Hartel  route,  or  slightly  more  below  the  level  of 
the  lower  border  of  the  zygomatic  process.  Consequently,  a  needle 
entered  at  the  lower  border  of  the  zygoma  should  be  well  above  it,  but 
if  passed  through  the  lower  part  of  the  sigmoid  notch  may  come  in 
contact  with  it. 

As  the  artery  passes  forward  and  inward  it  lies  parallel  to  the 
auriculo temporal  nerve,  above  and  in  front  of  the  inferior  dental  and 
along  the  lower  border  of  the.  external  pterygoid  muscle.  It  then 
runs  obliquely  forward  and  upward,  over  the  surface  of  this  muscle 
(pterygoid  portion).  In  its  third  or  sphenomaxillary  portion  the 
artery  runs  transversely  in  a  tortuous  manner,  and,  while  somewhat 
variable  in  its  course,  always  lies  below  the  superior  maxillary  nerve 
in  the  sphenomaxillary  fossa,  where  it  lies  in  close  relation  to  MeckePs 
ganglion. 

The  only  branch  of  this  vessel  of  particular  interest  to  us  is  the 
middle  meningeal,  which  is  given  off  opposite  the  sigmoid  notch,  and 
ascends  almost  vertically  to  the  foramen  spinosum  in  its  course.  It 
usually  lies  behind  the  transverse  tract  of  the  needle  in  a  lateral 


6O2  LOCAL   ANESTHESIA 

puncture,  but  may  occasionally  lie  more  anteriorly.  A  small  branch, 
the  small  meningeal,  passes  up  through  the  foramen  ovale,  but  this, 
with  the  internal  maxillary  vein,  lies  below  and  in  front  of  the  artery. 

Other  branches  are  either  of  small  size  or  are  situated  outside  of 
the  coarse  of  the  needle,  and  are  of  no  particular  concern  to  us  here. 

The  best  protection  against  the  injury  of  a  vessel  here,  as  well  as 
elsewhere,  in  making  deep  punctures  is  in  the  proper  selection  of  the 
needle  or  cannula,  combined  with  its  skilful  and  careful  use. 

By  the  use  of  a  small-calibered  needle  with  flat  point,  and  not  a 
coarse  needle  with  sharp,  long  point  with  cutting  edges,  there  is  little 
likelihood  of  a  serious  injury  to  a  vessel.  In  cases  in  which  injury 
does  occur  it  amounts  to  a  small  hematoma  or  slight  ecchymosis  at 
the  point  of  puncture,  which  is  probably  from  injury  of  a  vein,  the 
arteries  having  tougher  walls  and  being  more  easily  displaced. 

On  the  lateral  aspect  of  the  skull  in  the  transverse  methods  of 
approach  to  the  foramen  rotundum  and  sphenomaxillary  fossa  two 
routes  are  available:  one  above,  the  other  below,  the  zygoma.  The 
upper  route  rarely  reaches  the  foramen  rotundum,  but  enters  the 
sphenomaxillary  fossa  just  below  the  foramen.  The  best  method  of 
utilizing  this  route  is  to  enter  the  needle  high  up  on  the  cheek  in  the 
notch  formed  by  the  union  of  the  zygomatic  and  frontal  processes  of 
the  malar  bone.  From  this  point  the  needle  is  advanced  transversely 
inward,  when  it  impinges  against  the  great  wing  of  the  sphenoid  just 
above  the  pterygoid  ridge.  The  point  of  the  needle  is  now  success- 
ively lowered  until  it  slips  beneath  this  ridge  and  enters  the  fossa. 
It  is  now  advanced  about  i  cm.  further,  and  the  injection  made  at  a 
depth  of  about  4.5  to  5  cm.  from  the  surface. 

In  entering  this  fossa,  if  the  point  of  the  needle  is  advanced  too  far 
forward  it  strikes  upon  the  rough  upper  projection  of  the  tuber  maxil- 
lare,  along  which  it  must  feel  its  way  backward;  if  advanced  too  far 
backward  it  meets  the  external  pterygoid  plate  near  its  base,  and 
must  be  successively  advanced  forward  until  it  slips  over  the  sharp 
laterally  projecting  edge  of  this  bone  into  the  fossa  beyond  (Fig.  220). 

If  advanced  too  far  within  the  fossa,  it  is  possible  to  pass  beyond 
and  enter  the  nasal  cavity  through  the  sphenopalatine  foramen,  which 
lies  about  on  a  level  with  this  line  of  puncture. 

In  entering  the  fossa  from  below  the  zygoma  (Fig.  221)  there  are 
certain  dangers  to  be  avoided.  The  point  of  puncture  lies  below  the 
notch  on  the  malar  (formed  by  the  zygomatic  and  frontal  processes) 
and  about  on  a  lateral  plane  with  the  posterior  surface  of  the  tuber 
maxillare.  From  this  point  the  needle  is  advanced  inward  with  an 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  603 

upward  inclination,  passing  between  the  tuber  maxillare  in  front  and 
the  pterygoid  process  behind,  through  the  pterygomaxillary  fissure 
into  the  fossa  just  beyond,  to  a  depth  not  to  exceed  4.5  to  5  cm.;  the 
upward  inclination  of  the  needle  is  such  that  at  this  depth  the  point 
should  be  about  1.5  to  2  cm.  above  the  point  of  puncture. 

If  the  needle  is  advanced  too  far  inward,  and  particularly  if  the 
point  of  entrance  be  slightly  below  the  edge  of  the  zygoma  and  the 
angle  of  the  needle  be  too  high,  it  is  possible  to  pass  beyond  the 
sphenomaxillary  fossa  and  transfix  the  structures,  passing  through  the 
superior  orbital  fissure  or  even  enter  the  orbital  foramen. 

As  the  axis  of  the  foramen  rotundum  is  at  an  angle  with  this  and 
other  transverse  methods  of  puncture,  it  is  only  possible  in  about 
one- third  of  the  cases  to  enter  this  opening;  however,  the  fossa  just 
in  front  of  the  forearm  is  readily  reached  and  the  nerve  often  trans- 
fixed at  this  point,  or  the  solution  deposited  in  direct  contact  with  it. 

A  method  erroneously  attributed  to  Matas,  while  used  at  about 
the  same  time  by  him,  is  probably  to  be  credited  to  Schlosser.  This 
method  has  its  puncture  point  slightly  below  and  behind  the  malar 
prominence.  From  this  point  the  needle,  directed  backward,  upward, 
and  inward,  feels  its  way  along  the  posterior  surface  of  the  tuber  max- 
illare until  it  slips  beyond  its  posterior  projection  through  the  ptery- 
gomaxillary fissure  into  the  sphenomaxillary  fossa  at  a  depth  of  about 
4.5  to  5  cm.  from  the  surface. 

Harris  Method  for  Injecting  Superior  Maxillary  Nerve. — This 
method  is  quite  similar  to  other  lateral  methods  for  reaching  the 
foramen  rotundum.  The  needle  is  entered  through  the  cheek  in  the 
angle  formed  by  the  coronoid  process  and  the  undersurface  of  the 
malar  bone.  The  needle  is  advanced  upward  at  an  angle  of  40°  from 
the  horizontal  and  should  be  in  line  with  the  ascending  orbital  process 
of  the  malar  bone.  The  needle  passes  behind  the  back  wall  of  the 
antrum  and  in  front  of  the  anterior  border  of  the  external  pterygoid 
plate,  passing  through  the  pterygomaxillary  fissure  into  the  spheno- 
maxillary fossa.  The  depth  of  the  foramen  rotundum  is  usually  5 
to  6  cm.  from  the  surface  and  if  there  is  no  evidence  of  the  needle 
having  reached  the  nerve  at  this  depth  it  is  slightly  withdrawn  and 
directed  further  backward  in  contact  with  the  external  pterygoid 
plate  and  is  then  gradually  advanced  forward  by  repeated  thrusts 
until  it  slips  over  the  anterior  edge  of  this  bone  when  it  is  advanced 
i  cm.  within  the  sphenomaxillary  fossa  when  if  the  proper  angle  of 
40°  upward  has  been  maintained  it  should  be  in  contact  with  the 
nerve.  This  method  should  be  studied  in  connection  with  the  Offer- 


604  LOCAL   ANESTHESIA 

haus  method  which  gives  the  accurate  depth  from  the  surface  at 
which  the  foramen  will  be  reached.  This  injection  is  difficult  to 
make  and  is  one  of  the  most  dangerous  of  the  deep  injections  as  seri- 
ous results  may  follow  if  carelessly  or  inaccurately  done.  If  the 
needle  is  directed  too  high  and  advanced  too  deeply  it  may  wound  the 
third  or  sixth  nerve  at  the  sphenoidal  fissure  and  slightly  deeper 
along  this  higher  axis  may  reach  the  optic  nerve,  serious  results  may 
follow  injury  to  these  nerves  particularly  in  making  an  alcohol  in- 
jection. If  the  track  of  the  needle  is  too  low  or  it  is  advanced  too 
deeply  it  may  enter  the  posterior  nares. 

Occasionally  the  pterygomaxillary  fissure  is  so  closed  as  to  make 
the  entrance  of  the  needle  here  impossible;  in  this  case  resort  may 
be  had  to  the  Matas  orbital  route. 

In  discussing  this  fossa,  the  anatomic  variations  in  its  bony  sur- 
roundings, and  the  methods  of  puncture  Hartel  states  the  following: 

(In  this  discussion  of  the  various  methods  of  approach  the  Matas 
route  is  referred  to  as  a  transverse  route  beneath  the  zygoma.  This 
route,  while  used  by  Prof.  Matas  probably  independently  and  about 
the  same  time  (1898)  should,  I  believe,  be  credited  to  Schlosser.  The 
original  Matas  route  is  the  orbital  puncture  through  the  sphenomaxil- 
lary  fissure.) 

"Let  us  consider  next  the  lateral  entrance  (Fig.  220).  This  has 
a  sickle  shape,  which  in  its  superior  end  continues  into  the  inferior 
orbital  fissure.  The  posterior  margin  of  this  sickle  consists  of  a  bone 
corner  which  is  formed  by  the  anterior  boundary  of  the  lamina  ex- 
terna  of  the  pterygoid  process,  and  above  tapers  into  a  ridge  which 
separates  the  planum  infratemporale  from  the  planum  orbitale  of  the 
great  wing  of  the  sphenoid  bone,  and  is  furnished  with  a  process  called 
tuberculum  spinosum  (Fig.  220,  a,  x).  The  anterior  concave  margin 
of  the  sickle  is  formed  by  the  opposite  surface  of  the  tuber  maxillare. 

"According  to  the  greater  or  less  pneumatization  of  the  antrum 
of  Highmore,  the  tuber  maxillare  juts  out  behind  more  or  less,  so 
that  the  sickle  form  may  vary  from  a  small  fissure  ('  type  en  cornue/ 
Fig.  220,  c-e)  to  a  half-circle  ('typeovalaire,'  Chipault,  Fig.  220,  a-b). 
The  transverse  diameter  is  correspondingly  variable.  It  amounts 
(Table  II,  No.  9)  in  the  minimum  to  3  mm.;  in  the  maximum,  to  n 
mm.,  and  on  the  average,  to  5.4  mm.  A  'narrow  fossa'  with  a  width 
under  5  mm.  we  find  in  about  40  per  cent,  of  the  cases. 

"Besides,  there  are  the  varieties  of  the  posterior  margin,  which 
are  dependent  on  the  development  of  the  masseters.  The  under  part 
of  the  same,  which  belongs  to  the  pterygoid  process  and  almost 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  605 

always  presents  a  very  characteristic  corner,  which  we  wish  to  call 
Grenzleiste  (marginal  ridge),  projects  in  special. cases  sharply  and 
like  a  knife  opposite  the  entrance  of  the  fossa,  and  may  bear  a  prong, 
which  is  called  spina  pterygoidea  (Fig.  220,  d,  e,  y).  Just  so,  the 
superior  part  belonging  to  the  great  wing  of  the  sphenoid  bone  may 
be  either  smooth  or  form  an  elevation,  soon  becoming  pyramidal  in 
shape  or  ridge-like,  or  running  out  into  a  point,  the  tuberculum  spin- 
osum  already  mentioned.  Between  these  two  spines  a  ligament  may 
develop  similar  to  the  ligamentum  pterygospinosum  (Poirier) ,  which 
has  been  described.  The  different  types  of  the  entrance  of  the  fossa 
pterygopalatina  are  placed  together  in  Fig  220  and  in  Table  II,  No. 
10.  The  relations  of  the  entrance  to  the  fossa  are  of  importance  for 
the  ways  of  access  of  Matas  (i)  and  Offerhaus  (3).  As  far  as  the 
latter  "way  is  concerned,  it  is,  in  general,  not  practicable  if  the  point 
of  puncture  above  the  zygomatic  arch  is  chosen,  for,  according  to 
Table  II,  No  n,  the  needle  introduced  in  this  way  only  in  a  small 
portion  of  the  cases  (12  per  cent.)  reaches  the  superior  part  of  the 
fossa  which  receives  the  nervus  maxillaris;  but  also  for  the  Matas- 
Braun  way  unfavorable  varieties  of  the  entrance  present  great 
difficulties. 

"If  we  now  consider  the  interior  of  the  fossa,  this  is  also  subject 
to  great  changes.  Of  most  importance  to  us  is  the  posterior  wall 
with  the  surroundings  of  the  foramen  rotundum,  for  a  puncture  of 
the  nervus  maxillaris  can  be  successful  in  the  whole  region  only  if  it 
reaches  it  shortly  after  its  exit  from  the  foramen  rotundum,  before 
it  has  given  of!  its  branches.  This  posterior  wall  can  be  likewise 
strongly  changed  only  through  the  pneumatization  of  the  bones  form- 
ing it.  Sometimes  one  finds  the  entire  fossa  walled  up  transversely 
or  lengthwise  with  pneumatized  walls,  which  belong  to  the  sphenoid 
bone  or  else  to  the  palatine  bone. 

"If  we  now  next  test  the  bony  skull  as  to  the  possibility  of  punc- 
turing the  foramen  rotundum  directly  by  the  Matas  way  (should  be 
Schlosser — Author),  then  it  is  shown  that  only  in  33  per  cent,  of  the 
cases  (Table  II,  No.  12)  does  the  possibility  exist  of  penetrating  with 
the  point  of  the  cannula  more  or  less  deeply  into  the  foramen,  a 
possibility  which  by  the  orbital  way  (original  Matas  route — Author) 
— incidentally  noted — is  much  greater  (89  per  cent.) .  Consequently, 
with  the  lateral  puncture  we  cannot  practically  reckon  on  a  direct 
injection  of  the  foramen  rotundum,  but  must  content  ourselves  with 
washing  the  nervus  maxillaris  in  the  fossa. 

"If  we  now  seek  fixed  points  for  a  successful  puncture  of  the  fossa 


6o6 


LOCAL   ANESTHESIA 


sphenomaxillary,  then  here  also  the  method  of  concentric  puncture  is 
of  importance :  for,  on  the  one  hand,  we  must  shift  the  puncture  point 
as  much  as  possible  to  the  front,  in  order  to  carry  the  needle  to  the 
posterior  wall  of  the  fossa;  on  the  other  hand,  it  may  happen  that, 
with  a  puncture  point  shifted  too  far  to  the  front,  the  tuber  maxillare 
obstructs  the  approach.  Most  frequently  the  puncture  point  by 
which  it  is  possible  to  reach  the  exit  of  the  foramen  rotundum  lies 
under  the  sutura  zygomatico-malar,  which  is  marked  by  a  promi- 


Fig.  226. — Skiagraph  of  needle  transfixing  gasserian  ganglion  by  Hartel  route;  shows 
axis  of  needle  in  relation  to  teeth  and  bony  parts  of  face  and  skull.  Injected  vessels  are 
also  seen.  (Original  illustration  from  collection  of  Prof.  Matas.) 

nence,  and  in  the  living  subject  is  usually  palpable  or  somewhat  be- 
hind this  same  suture.  (See  Table  II,  No.  13.) 

"Gliding  backward  on  the  tuber  maxillare  we  come  to  the  en* 
trance  of  the  fossa,  and  guide  ourselves  now  to  the  opposite  posterior 
wall,  while  we  seek  to  come  into  the  turning-corner  of  ridges  bordering 
this  wall,  since  with  a  higher  puncture  (Fig.  216)  we  are  in  danger  of 
coming  into  the  orbit,  with  a  deeper  one  into  the  nasal  cavity. 
Further,  we  must  reflect  that  after  passing  the  entrance  we  dare  not 
go  too  deep — i  cm.  at  the  most,  which  we  can  control  by  our  sliding 
catch.  The  total  depth  amounts  to  45  to  57  mm.,  on  the  average 
50  mm.  (See  Table  II,  No.  14.) 

"Favorable  for  the  injection  into  the  fossa  is  the  circumstance 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  607 

that  it  is  filled  with  loose  masses  of  fat,  which  permit  a  good  diffusion 
of  the  injected  solution  into  the  vicinity.  The  nervus  maxillaris 
(Fig.  223)  itself  lies  in  the  uppermost  part  of  the  fossa  sphenomaxil- 
lary,  and  is  fixed  to  its  roof  by  connective  tissue.  In  its  course  it 
takes  an  S-form,  which  in  a  sagittal  direction  comes  out  of  the  fora- 
men rotundum;  it  bends  laterally,  in  order  to  arrive  at  the  sulcus 
infra-orbitalis  of  the  upper  jaw,  when  it  takes  the  sagittal  direction 
again.  The  orbital  puncture  follows  the  direction  of  this  nerve- 
trunk  itself,  which  in  its  manner  presents  a  similar  axial  puncture." 
Braun  Method. — This  is  an  effective  and  simple  means  of  reach- 


Fig.  227. — Angle  and  point  of  crossing  within  the  skull  of  the  axes  of  the  needle  in  the 
Hartel  route,  if  continued  backward  in  a  bilateral  puncture.  (Original  illustration  from 
collection  of  Prof.  Matas.) 

ing  the  trunk  of  the  third  division  at  its  exit  from  the  skull,  and  fairly 
as  accurate  as  the  Offerhaus,  Hartel,  or  any  other  route  for  reaching 
the  trunk  of  the  nerve  and  much  easier  executed. 

The  needle  is  entered  at  about  the  midpoint  of  the  zygoma  on 
its  undersurface,  and  directed  transversely  inward  until  it  strikes 
upon  the  external  plate  of  the  pterygoid  process  near  its  base  (Fig. 
228).  It  will  be  seen,  from  a  reference  to  the  position  of  these  parts, 
that  the  foramen  ovale  lies  directly  back  of  the  base  of  this  plate  and 
on  the  same  anteroposterior  plane,  consequently  the  depth  to  the 
external  plate  at  its  base  is  the  depth  to  the  foramen  ovale,  but  on  a 
slightly  posterior  plane,  about  i  cm.  Having  now  determined  the 


6o8 


LOCAL   ANESTHESIA 


depth  from  the  surface  necessary  to  penetrate,  this  is  marked  on  the 
needle,  which  is  partially  withdrawn,  and  the  point  redirected  slightly 
backward,  in  which  direction  it  is  advanced  to  the  determined  depth. 
When  the  nerve  is  reached  this  is  recognized  by  the  usual  paresthesia 
along  its  branches. 

The  method  of  Ojferhaus  is  a  decidedly  ingenious  and  valuable  ac- 
quisition.    To  him  is  due  the  credit  of  attempting  the  first  time  to 


i, 

«.  „.-  -  Foramen 
\_  -i         ovale 


Fig.  228. — Lateral  routes  of  in  jection  for  foramen  ovale :  i,Offerhaus;  2,  Braun.     (Braun.) 

locate  the  relative  positions  of  the  foramina  ovale  and  rotundum  by 
anatomic  measurements  made  on  the  base  of  the  skull.  This  method 
aims  to  make  the  injections  immediately  beneath  the  foramina, 
reaching  the  nerves  just  as  they  leave  the  openings,  at  their  approxi- 
mately determined  depth  from  the  surface.  This  method,  when  ap- 
plied with  some  judgment,  making  allowances  for  anatomic  varia- 
tions in  individual  cases  by  slightly  manipulating  the  point  of  needle 
until  it  comes  in  contact  with  the  nerve,  which  is  recognized  by  the 


THE    HEAD,    SCALP,    CRANIUM,    BRAIN,    AND    FACE 


609 


characteristic  paresthesia  along  its  branches,  will  be  found  to  be  a 
highly  useful  and  valuable  procedure. 

In  a  study  of  50  skulls  Offerhaus  found  that  the  distance  between 
the  foramen  ovale  is  approximately  the  distance  from  the  two  outer 
surfaces  of  the  alveolar  processes,  opposite  or  just  behind  the  last 
molar  tooth,  at  the  point  where  the  processus  pyramidalis  ossis  pala- 


Fig.  2  29. — Offerhaus  method  for  measuring  base  of  skull  to  determine  distance  of  fora- 
men ovale  from  articular  tubercle.     (Braun.) 

tini  joins  the  maxillary  bones;  this,  then,  is  the  distantia  interalveo- 
laris  externa  (D.  A.  E.),  and  equals  the  distantia  foramina  ovale 
(D.  F.  O.)  (Fig.  229). 

The  distance  between  the  foramina  rotundum  is  the  same  as  the 
distance  between  the  alveolar  processes  of  the  maxilla  on  the  inner 
side,  behind  or  along  the  side  of  the  last  molar. 

Distantia  interalveolaris  interna  (D.  A.  I.). 

39 


6io 


LOCAL   ANESTHESIA 


The  axis  in  which  lie  the  foramina  rotundum  reaches  the  surface 
at  the  upper  border  of  the  zygomas  at  the  point  where  the  temporal 
portion  merges  with  the  malar;  this  is  about  the  midpoint  of  the 
zygomatic  arch,  the  linea  interzygomatica. 

The  foramina  rotunda  lie  about  2  to  4  mm.  just  above  and  behind 
this  line.  The  axis  in  which  lie  the  foramina  ovale  passes  over  the 
eminentia  articularis  and  through  the  articular  tubercles;  occasion- 
ally the  foramen  lies  2  or  3  mm.  back  of  this  line,  but  as  the  axis  of 
the  nerve  is  downward  and  forward  it  usually  passes  through  this 
axis.  While  the  relative  position  and  distances  between  these  parts 


Fig.  230. — Method  of  using  Offerhaus  calipers.     (Braun.) 

may  vary  slightly  in  different  skulls,  as  well  as  on  the  two  sides  of 
the  same  skull,  these  measurements  may  be  relied  on  as  approxi- 
mately correct,  varying  only  within  a  few  millimeters. 

In  the  clinical  application  of  this  method  the  distantia  interalveo- 
laris  externa  is  measured  with  an  ordinary  pair  of  calipers  or  a  com- 
pass; this  is  usually  found  to  be  about  5  cm.,  and  equals  (D.  F.  O.) 
distantia  foramina  ovalis;  the  distantia  intertubercularis  is  next  de- 
termined by  specially  constructed  calipers  (Fig.  230),  though  any 
instrument  adapted  to  this  purpose  will  do.  On  the  Offerhaus  cali- 
pers there  is  a  movable  part,  which  is  attached  to  the  point  and  pro- 
jects outward  to  indicate  the  direct  angle  of  puncture.  These  are 
usually  placed  on  after  the  distance  has  been  determined,  which  is 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  6ll 

shown  by  a  scale  to  which  the  arms  of  the  caliper  are  attached  and 
along  which  they  move.  As  the  articular  tubercles  are  usually  easily 
felt,  just  in  front  of  the  temporomaxillary  articulation  at  the  root  of 
the  zygoma,  this  measurement  is  very  simply  made.  In  fleshy  in- 
dividuals a  small  allowance,  about  i  cm.,  may  have  to  be  allowed  for 
soft  parts. 

This  distance  is  usually  about  14  cm.  We  then  subtract  from 
this  the  distance  between  the  foramina  ovale,  5  cm.,  previously  de- 
termined by  measurement,  between  the  alveolar  processes,  and  divide 

by  two.  — -  =  4-5  cm.,  the  distance  along  the  linea  intertuber- 

cularis  which  the  needle  must  travel  to  reach  the  nerve-trunk. 

Occasionally,  the  ossification  of  the  ligament  pterygospinosum 
presents  a  bony  barrier  to  the  passage  of  the  needle  along  the  linea 
intertubercularis.  When  this  exists  there  is  usually  an  opening 
through  this  plate  near  the  base  of  the  skull,  just  to  .the  side  of  the 
foramen  ovale ;  this  is  best  found  by  feeling  with  the  needle  along  the 
smooth  surface  of  the  planum  infratemporalis  toward  the  foramen, 
and  the  opening  through  the  obstructing  plate  is  usually  entered 
without  much  difficulty. 

For  injecting  the  second  division  the  linea  in terzygomatic  is  de- 
termined by  measuring  with  the  large  calipers  the  distance  between 
the  midpoints  on  the  two  zygomatic  arches;  from  this  is  subtracted 
the  distance  between  the  inner  surfaces  of  the  alveolar  processes  at 
the  last  molar  tooth,  and  this  figure  divided  by  two  in  the  same  way 
as  for  the  preceding  method. 

This  then  gives  us  the  depth  to  which  the  needle  must  travel  to 
reach  the  second  division  of  the  fifth.  Offerhaus  advises  that  the 
needle  be  entered  above  the  zygomatic  arch  for  reaching  the  trunk 
of  this  nerve,  but  where  it  is  desired  to  make  the  injection  at  the 
foramen  rotundum  the  needle  is  entered  below  the  zygoma,  directed 
slightly  upward.  A  very  large  coronoid  process  may  check  the  pas- 
sage of  the  needle  here,  in  which  case,  if  the  mouth  is  opened  wide, 
this  descends  out  of  the  way. 

The  same  difficulties  may  be  encountered  here  in  passing  the 
needle  within  the  sphenomaxillary  fossa,  as  already  mentioned  in 
discussing  those  regions,  and  the  same  rule  should  be  applied  here  to 
overcome  these  difficulties.  Occasionally,  this  method  may  have  to 
be  abandoned  in  cases  where  the  sphenomaxillary  fissure  is  reduced 
to  a  mere  slip,  too  narrow  for  the  passage  of  the  needle  by  the  too 
close  approach  of  the  tuber  maxillare  to  the  pterygoid  process.  In 
this  case  the  Matas  route  should  then  be  tried. 


6l2 


LOCAL    ANESTHESIA 


Offerhaus  recommended  that  2  c.c.  of  from  0.50  to  0.75  per  cent, 
cocain  and  adrenalin  be  used  in  making  either  injection.  It  would, 
however,  seem  best,  in  the  writer's  opinion,  to  use  stronger  solutions 
of  novocain  and  adrenalin  (2  c.c.  of  a  2  per  cent,  solution),  as  is  sug- 
gested by  most  operators  making  these  injections. 

Offerhaus  states  that  complete  analgesia  usually  occurs  in  about 
fifteen  minutes  and  lasts  about  one  hour.  This  time  could  probably 
be  lengthened  by  the  use  of  stronger  solutions,  as  suggested. 


Fig.  231. — Novocain  anesthesia  of  the 
right  gasserian  ganglion,  tested  immedi- 
ately after  injection.  (Hartel.) 


Fig.  232. — Anesthesia  following  alcohol 
injection  in  the  left  ganglion,  tested  im- 
mediately following  injection.  (Hartel.) 


The  utilization  of  these  methods  of  measurement,  as  taught  us 
by  Offerhaus,  may  be  applied  to  any  other  route  of  puncture  applied 
to  the  same  region,  and  should  serve  as  a  valuable  guide  in  determin- 
ing the  depth  of  penetration. 

Technic  of  Injection  of  the  Gasserian  Ganglion  and  Its  Branches. — 
The  technic  of  making  all  deep  injections  whether  for  purposes  of 
surgical  anesthesia  or  for  neuralgia  should  be  the  same.  The  neural- 
gic patient  should  not  have  a  general  anesthetic  unless  it  is  impossible 
to  handle  them  otherwise  but  the  nerve  first  sought  for  under  local 
anesthesia  and  blocked  by  these  injections  and  the  entire  distribu- 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  613 

tion  of  the  nerve  anesthetized,  as  it  is  only  then  that  we  can  feel  abso- 
lutely certain  in  the  great  majority  of  cases  that  the  needle  point  has 
reached  or  entered  the  nerve. 

The  point  on  the  skin  through  which  the  needle  is  to  enter  is 
first  anesthetized.  The  needle  entered  at  this  point  is  slowly  ad- 
vanced injecting  the  solution  lightly  as  it  is  pushed  forward;  0.5  per 
cent,  novocain  with  about  5  drops  of  adrenalin  to  the  ounce  is  usually 
preferred.  The  injecting  of  the  solution  as  the  needle  is  advanced 
makes  it  less  likely  to  injure  a  vessel  as  they  are  more  likely  to  slip 
to  one  side  and  as  the  adrenalin  immediately  contracts  them  their 
reduced  size  with  contracted  thickened  walls  makes  them  still  less 
likely  to  be  injured. 

The  needle  should  be  about  10  cm.  long  and  0.8  mm.  thick  and 
have  a  short  sharply  beveled  point.  Such  a  needle  should  it  enter 
a  vessel  will  at  most  produce  a  slight  negligible  hematoma  which  will 
be  absorbed  and  I  have  never  seen  any  bad  effects  to  result  from  such 
an  injury.  No  force  should  ever  be  used  in  advancing  the  needle, 
but  should  an  obstruction  be  encountered,  which  may  be  a  bony  wall, 
should  the  direction  of  the  needle  be  faulty,  or  an  ossified  ligament, 
it  should  be  slightly  withdrawn  and  redirected  slightly  to  one  side 
or  the  other  so  as  to  pass  the  obstruction.  When  the  nerve  is  reached, 
it  is  usually  indicated  by  a  slight  pain  like  an  electric  shock  or  thrill 
along  its  peripheral  distribution ;  in  the  case  of  the  superior  maxillary 
nerve  along  the  side  of  the  face,  upper  teeth  or  side  of  the  nose,  and 
in  the  case  of  the  inferior  maxillary  division  the  sensation  is  in  the 
lower  jaw  and  tongue.  If  the  gasserian  ganglion  is  reached  the 
sensation  may  be  in  either  of  the  above  nerves,  and  in  addition  pain 
in  the  eye  or  over  the  orbit. 

When  it  is  felt  that  the  proper  point  has  been  reached,  the  needle 
is  not  disturbed  but  an  additional  quantity  of  the  local  anesthetic 
injected.  If  the  needle  is  properly  placed  very  little  is  needed  to 
anesthetize  any  nerve-trunk,  ^  to  i  dram  at  most,  and  the  ganglion 
and  parts  within  the  skull  seem  much  more  susceptible  to  its  influence 
than  the  external  branches.  After  a  delay  of  a  few  minutes  the 
peripheral  distribution  of  the  nerve  is  tested  for  anesthesia  and  if 
not  complete  slightly  more  is  injected  but  should  there  be  no  change 
in  sensation  it  is  quite  certain  that  the  needle  has  been  inaccurately 
placed  when  it  can  be  either  advanced  farther  or  partially  withdrawn 
and  redirected  as  the  case  may  indicate.  Occasionally  the  usual 
peripheral  sensations  which  occur  when  the  needle  reaches  the  nerve- 
trunk  may  be  absent;  consequently  they  should  not  be  invariably 


6 14  LOCAL    ANESTHESIA 

depended  upon,  but  if  it  is  felt  that  the  needle  has  been  correctly 
placed  an  injection  of  the  local  anesthetic  will  produce  anesthesia  in 
the  field  of  distribution  of  the  nerve.  In  the  event  of  the  injection 
being  made  for  surgical  anesthesia,  as  in  an  extensive  resection  of 
the  maxilla,  the  needle  may  be  permitted  to  remain  in  position  should 
it  not  be  in  the  way,  as  it  may  be  necessary  to  repeat  the  injection 
before  the  completion  of  the  operation,  should  the  anesthesia  show 
signs  of  failing.  As  a  rule  the  thorough  injection  of  the  ganglion  or 
any  of  its  branches  should  produce  a  surgical  anesthesia  of  an  hour 
or  longer  but  occasionally  the  anesthesia  is  much  shorter. 

In  injections  to  reach  the  foramen  ovale  certain  points  are  to  be 
observed.  In  passing  the  needle  by  the  Hartel  route  through  the  cheek, 
a  finger  of  one  hand  is  placed  in  the  mouth  to  guide  the  needle  be- 
tween the  ramus  of  the  jaw  and  the  buccal  mucous  membrane  as 
some  manipulation  of  the  needle  may  be  necessary  here  to  safely  pass 
this  point  without  entering  the  mouth. 

As  the  point  of  the  needle  searches  out  the  foramen  ovale  beneath 
the  base  of  the  skull,  should  it  be  directed  too  far  backward,  it  may 
wound  the  Eustachian  tube  which  is  felt  as  a  sharp  pain  running 
back  to  the  ear;  in  such  case  the  needle  should  be  slightly  withdrawn 
and  redirected  slightly  forward  of  this  position.  Another  accident 
which  may  happen  in  searching  for  the  foramen  ovale,  but  more  par- 
ticularly by  the  lateral  routes,  should  the  needle  be  directed  too  low 
is  puncture  of  the  pharyngeal  wall,  which  is  felt  as  a  soreness  or  pain 
in  the  throat. 

Method  of  Injecting  Alcohol. — With  the  needle  point  accurately 
placed  and  the  nerve  well  injected  with  novocain  as  shown  by  com- 
plete peripheral  anesthesia,  a  delay  of  five  minutes  is  permitted  to  allow 
the  thorough  diffusion  of  the  local  anesthetic  as  well  as  to  permit  the 
excess  of  fluid  to  escape  into  the  surrounding  parts  to  avoid  its  too 
great  diluting  influence  upon  the  alcohol.  While  ordinarily  80  per 
cent,  alcohol  is  sufficient  to  destroy  nerve- tissue  when  properly  in- 
jected, it  is  preferable  when  injecting  into  a  field  already  saturated 
with  fluid  to  use  a  smaller  quantity  of  stronger  alcohol.  I  almost 
invariably  use  95  per  cent,  when  making  the  injection  in  this  way. 
The  alcohol  should  never  be  injected  rapidly,  but  always  very  slowly, 
a  few  drops  at  a  time. 

It  is  often  possible  if  the  nerve  has  previously  been  well  anesthe- 
tized that  the  alcohol  will  produce  no  disturbance  but  more  often  a 
slight  burning  is  felt  which  disappears  after  ten  to  twenty  seconds 
to  reappear  again  as  an  additional  2  or  3  drops  are  injected.  This 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  615 

recurs  a  few  times  when,  if  sufficient  time  has  been  allowed  to  elapse, 
the  last  few  injections  may  excite  no  sensation.  If  the  nerve  has  been 
insufficiently  anesthetized  before  the  alcohol  is  injected,  this  pain  is 
always  more  pronounced,  and  in  such  cases  the  alcohol  should  be 
more  slowly  injected,  allowing  sufficient  time  for  each  2  or  3  drops 
to  exert  its  full  destructive  influence  and  all  pain  to  subside  before 
more  is  injected.  When  the  alcohol  is  used  without  the  preliminary 
anesthetic  injections  this  pain  is  of  an  intense  burning  character  and 
radiates  along  the  distribution  of  the  nerve,  and  in  the  case  of  the 
ganglion  it  often  feels  like  an  electric  shock  in  the  side  of  the  head, 
subsiding  in  a  few  seconds,  followed  by  a  progressively  increasing 
anesthesia  in  the  peripheral  parts  as  more  and  more  is  injected. 
The  amount  of  alcohol  necessary  to  produce  a  complete  destruction 
of  the  nerve  with  lasting  anesthesia  varies  from  %  to  2  c.c.,  i  c.c.  being 
sufficient  for  any  nerve-trunk  but  in  the  case  of  the  ganglion  more 
may  be  needed.  It  is  only  possible  to  determine  the  exact  amount 
necessary  when  injecting  an  unanesthetized  nerve  when  the  resulting 
peripheral  anesthesia  serves  as  a  guide  and  the  injections  continued 
within  the  above  limits  until  the  peripheral  anesthesia  becomes  per- 
manent and  complete.  When  injecting  an  anesthetized  nerve  it  may 
occasionally  be  found  necessary  to  repeat  the  injection,  more  often 
with  the  ganglion;  should  the  resulting  anesthesia  be  incomplete, 
and  this  plan  is  usually  to  be  preferred  rather  than  take  the  risk  of 
serious  after-effects  if  the  injection  be  too  liberally  made.  Besides, 
very  few  patients  will  permit  an  alcoholic  injection  without  some 
preliminary  anesthetic  injections. 

Action  of  Alcohol  Injections. — The  curative  effects  of  alcohol  in- 
jections in  neuralgia  is  due  to  its  destructive  action  on  the  tissues. 
All  tissue  suffers  alike  though  not  to  the  same  degree,  the  more  highly 
organized  and  more  delicate  tissues  are  more  markedly  affected.  In 
deep  injections  of  limited  quantity  the  tissues  undergo  an  aseptic 
necrosis  and  are  gradually  replaced  by  fibrous  tissue.  If  superficially 
injected  in  contact  with  the  skin  sloughing  may  occur. 

For  these  reasons  the  minimum  quantity  known  to  produce  the 
desired  effect  should  be  adhered  to  and  the  needle-point  should 
always  be  in  contact,  if  not  within,  the  nerve  to  be  injected  and  the 
alcohol  always  very  slowly  injected  a  few  drops  at  a  time.  The  re- 
sulting destruction  of  tissue  produces  a  break  in  the  nerve-trunk 
which  is  slowly  replaced  by  fibrous  tissue.  Nerves  with  high  trophic 
supply  such  as  branches  of  the  fifth  nerve  gradually  reform  and  often 
with  a  return  of  the  symptoms  when  they  should  be  reinjected.  This 


6l6  LOCAL    ANESTHESIA 

process  of  regeneration  takes  from  nine  months  to  a  year  or  longer. 
In  the  case  of  the  gasserian  ganglion  when  once  well  injected  the 
effect  lasts  much  longer  and  is  usually  permanent.  Common  sensa- 
tion returns  to  the  area  of  the  injected  nerve  after  several  weeks  but 
the  pain  sense  remains  absent  until  after  regeneration  of  the  nerve, 
although  the  area  affected  becomes  gradually  reduced  in  size.  As 
the  effect  of  an  alcohol  injection  is  equivalent  to  a  section  of  the  nerve 
it  should  never  be  applied  to  a  mixed  or  motor  nerve  unless  it  is  in- 
tended to  paralyze  it  as  in  cases  of  muscle  spasm.  In  a  few  cases  of 
sciatica  in  which  the  nerve  has  been  successfully  reached  by  the  in- 
jection, paralysis  has  resulted.  The  quantity  usually  injected  is  i 
c.c.  of  80  per  cent,  alcohol  for  a  nerve-trunk,  the  ganglion  often 
requiring  slightly  more,  up  to  2  c.c.  Where  a  nerve  has  previously 
been  injected  by  an  anesthetic  solution  a  smaller  quantity,  10  or  12 
minims  of  95  per  cent,  alcohol,  can  be  used  to  compensate  for  the 
diluting  effect  of  the  fluid  already  in  the  tissues. 

The  minimum  quantity  necessary  to  produce  the  desired  result 
should  always  be  adhered  to,  particularly  in  such  dangerous  regions 
as  the  foramen  rotundum  or  gasserian  ganglion;  otherwise  the  effect 
upon  the  surrounding  parts  may  produce  the  most  serious  conse- 
quences, and  if  too  liberally  made  at  any  point,  it  is  possible  for  in- 
fection to  result  with  abscess  formation.  This,  however,  practically 
never  occurs  with  the  proper  technic  and  has  never  been  observed 
in  the  experience  of  the  author  and  his  associates ;  at  most  there  re- 
sults a  slight  soreness  and  induration  at  the  point  of  injection. 

Disturbances  Following  Alcohol  Injection  of  Gasserian  Ganglion. — 
As  the  motor  nerves  to  the  muscles  of  mastication,  temporal,  masse- 
ter  and  pterygoid  are  distributed  with  the  third  division  of  the  fifth 
nerve  more  or  less  muscular  paralysis  of  these  parts  is  expected,  fol- 
lowing an  injection  at  or  within  the  foramen  ovale.  This  results  in 
a  falling  of  the  jaw  toward  the  paralyzed  side  with  inability  to  mas- 
ticate on  that  side,  but  this  is  often  not  noticed  by  the  patient  as  he 
has  accustomed  himself  to  masticate  almost  exclusively  on  the  un- 
affected side.  Until  the  patient  accustoms  himself  to  the  anesthesia 
of  the  side  of  the  tongue  and  cheek  these  parts  may  be  bitten.  Mo- 
tion, like  sensation,  is  restored  much  quicker  than  the  pain  sense 
and  the  paralysis  may  not  be  noticeable  after  a  few  months,  and  is 
rarely  ever  complete  but  the  fact  of  its  occurrence  should  make 
double  ganglion  injections  with  alcohol  a  matter  of  some  considera- 
tion, and  when  done  only  the  minimum  quantity  necessary  to  control 
pain  should  be  used  and  this  accurately  placed  in  the  ganglion  so 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE  617 

that  the  motor  root  which  lies  behind  and  beneath  may  escape  the 
full  effect. 

Ocular  Dangers. — As  the  results  of  a  successful  alcohol  injection 
of  the  ganglion  are  equivalent  to  a  gasserectomy  we  have  all  of  the 
resulting  disturbances,  anesthesia  of  the  cornea  with  loss  of  trophic 
control  and  the  risk  of  keratitis.  Consequently  all  patients  should  be 
advised  of  this  possibility,  and  it  is  desirable  that  an  oculist  take 
charge  of  the  eye.  Should  the  anesthesia  of  the  cornea  persist  for 
an  hour  after  the  injection  the  upper  lid  should  be  fastened  down  by 
adhesive  plaster  which  should  be  removed  daily  and  the  conjunc- 
tival  sac  washed  out  with  boracic  acid  at  which  time  the  eye  may  be 
tested  for  returning  sensation.  If  anesthesia  persists  for  several  days 
it  is  better  to  permanently  wear  a  collodion  shield  which  can  be  re- 
moved daily  for  attention  to  the  eye.  Closing  the  lid  by  means  of 
pads  of  gauze  or  cotton  is  dangerous  as  the  lids  may  open  beneath 
the  pad  and  the  anesthetized  eye,  not  feeling  the  contact,  serious 
damage  may  result. 

Occasionally,  dilatation  of  the  pupil,  paralysis  of  the  abducens  or 
nystagmus  may  occur  and  are  accounted  for  by  the  alcohol  reaching 
the  nerves  to  the  eye  in  the  lateral  wall  of  the  cavernous  sinus  (see 
Figs.  213,  214).  As  a  rule  these  phenomena  are  transient  and  pass 
off  after  a  few  hours.  Other  phenomena  which  may  be  observed 
are  dizziness,  vomiting  and  severe  pain  in  the  base  of  the  skull; 
this  is  no  doubt  due  to  the  injection  having  been  too  deeply  made, 
the  needle  passing  beyond  the  ganglion  into  the  cavum  Meckeli  in 
which  case  it  flows  back  into  the  posterior  fossa  of  the  skull  (see 
Anatomy,  page  598).  Transient  deafness  and  facial  paresis  may  be 
explained  in  the  same  way  by  the  alcohol  reaching  the  seventh  and 
eighth  nerves  as  it  flows  backward  along  the  dura  mater  over  the 
petrous  bone.  To  guard  against  this  danger  when  the  needle  is 
deeply  placed  in  the  region  of  the  ganglion,  gentle  aspiration  should 
be  resorted  to  before  injecting  the  alcohol.  If  clear  fluid  is  with- 
drawn, which  is  cerebrospinal  fluid,  the  needle  is  too  deeply  placed 
and  should  be  slightly  withdrawn  until  the  fluid  no  longer  appears 
before  making  the  injection.  To  minimize  the  possible  unpleasant 
after-effects  the  injections  should  always  be  made  with  the  patient 
in  the  recumbent  position  and  this  position  should  be  maintained 
for  at  least  an  hour. 

Area  Supplied  by  Fifth  Nerve. — Hartel  has  done  considerable 
work  in  clearing  up  certain  inaccuracies  and  uncertainties  which  ex- 
isted regarding  the  areas  of  distribution  of  the  different  branches  of 


6i8 


LOCAL   ANESTHESIA 


the  fifth  nerve.  He  shows  these  areas  as  taught  in  most  of  our  text- 
books, and  in  Figs.  231-235  shows  a  number  of  anesthetized  surfaces 
outlined  immediately  after  unilateral  ganglion  injections.  The  tests 
were  made  with  needles  on  patients  sufficiently  intelligent  to  make 
comparatively  accurate  observations;  certain  inaccuracies  are,  how- 
ever, bound  to  occur,  as  marginal  areas  show  diminished  sensibility 
and  adjacent  surfaces  are  overlapped  by  the  opposite  nerve  in  a  zig- 
zag manner. 

In  the  median  line  of  the  face  the  limits  between  the  two  sides 


Fig.  233. — Novocain  anesthesia  of 
right  gasserian  ganglion,  tested  immedi- 
ately after  the  injection.  (Hartel.) 


Fig.  234. — Novocain  anesthesia  of 
right  gasserian  ganglion,  tested  immedi- 
ately after  the  injection.  (Hartel.) 


were  rather  sharply  defined,  as  variations  were  not  so  numerous  as 
had  previously  been  supposed;  still  this  overlapping  may  take  place 
sufficiently  in  spots  to  make  it  always  advisable  to  anesthetize  both 
sides  in  operations  approaching  the  median  line. 

On  the  skull,  in  the  midline,  the  area  of  anesthesia  extended  well 
up  toward  the  vertex  capitis,  but  laterally  in  the  region  of  the  auricle 
some  variations  were  met  with.  He  calls  attention  to  this  extended 
area  of  anesthesia  as  offering  favorable  opportunities  by  this  method 
for  trephining,  etc.,  upon  the  sinciput. 

"In  the  face  the  area  of  distribution  of  the  cervical  nerves  (nervus 


THE    HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


619 


auricularis  magnus,  cutaneous  colli)  projects  from  below  laterally 
more  or  less  extensively  into  the  trigeminus  region,  so  that  we  never 
can  reckon  on  pure  trigeminus  anesthesia  in  the  region  of  the  auricle, 
lateral  temples,  cheeks  on  the  sides,  the  parotid  gland,  at  the  angle 
of  the  jaw  and  chin,  and  hence  must  always  prefer  infiltration  to 
ganglion  injection. 

.  "Relative  to  the  innervation  of  the  face,  observations  which  we 
have  made  after  alcohol  injection  as  to  the  capacity  for  regeneration 
of  the  sensibility  are  of  interest.  Figure  235  shows  the  areaofdif- 


Fig.  235. — Anesthesia  twelve  days 
after  alcohol  injection  of  right  gasserian 
ganglion.  (Hartel.) 


Fig.  236. — Same  as  Fig.  235,  twenty-five 
days  after  injection.     (Hartel.) 


fusion  of  the  analgesia  twelve  days  after  the  alcohol  injection  into 
the  ganglion  Gasseri;  Fig.  236,  the  same  twenty-five  days  after. 
We  see  clearly  how,  especially  in  the  frontal  regions  of  the  margins, 
collateral  tracts  of  sensibility  are  developed.  In  the  same  category 
the  observation  belongs  that  after  ganglion  injection  the  anesthesia 
died  out  earliest  in  those  regions  whose  nerves  were  treated  earlier 
with  peripheral  alcohol  injection.  If  we  compare  our  areas  of  anes- 
thesia with  the  anesthesias  found  by  Krause,  after  the  extirpation 
of  the  ganglion  Gasseri,  then  we  find  that  ours  are  more  extended 
and  approach  more  closely  to  the  statements  of  the  anatomists. 


62O 


LOCAL   ANESTHESIA 


This  is  attributable  to  the  fact  that  our  tests  were  undertaken  imme- 
diately after  the  injection,  while  Krause,  for  independent  reasons, 
first  undertood  the  tests  of  sensibility  eighteen  days  after  the 
operation. 

"2.  Deep  Sensibility. — By  ganglion  injection  the  collective  bones 
and  soft  parts  of  the  face  become  anesthetic,  as  far  as  they  belong 
to  the  area  of  distribution  of  the  trigeminus.  If  the  operation 

approaches    the    median    line, 
bilateral    anesthesia   is    to    be 
preferred.     Resections    of    the 
j        upper  jaw,   operations   on  the 


Fig.    237. — Sensory    innervation  of   the 


thoroughly  feasible  under  this 
anesthesia. 

"The  mucous  membranes  of 
the  eye  and  nose  are  certainly 
without  feeling,  as  well  as  the 
conjunctiva  and  cornea.  The 
corneal  reflex  dies  out,  also  the 
sneezing  reflexes  of  the  nasal 
mucous  membranes,  but  on  the 
contrary  the  vomiting  reflex  of 
the  pharynx  does  not.  The 
accessory  cavities  of  the  nose 
are  likewise  anesthetic.  Rad- 


tongue:  i  and  2,  Vagus  nerve  (dotted);  3  i°al     Operations    of    empyemas 

and  5,  glossopharyngeus  (oblique  lines)  54,  of     the     antrum     of    Highmore 

and  6,  lingual  nerve  (horizontal  lines).  are  feasible  with  unilateral 
(After  Zander  and  Spalteholz.)  . 

ganglion    anesthesia.     For    the 

ethmoid  cavity  double  anesthesia  is  always  to  be  recommended 
(Fig.  198).  Observations  concerning  the  sphenoid  sinus  and  the 
hypophysis  are  not  available. 

In  the  oral  cavity  complete  anesthesia  of  the  teeth,  jaws  and  hard 
palate  can  be  depended  upon.  The  soft  palate  usually  receives 
fibers  from  the  glossopharyngeal  plexus  and  consequently  may  retain 
some  sensation.  The  anterior  two-thirds  of  the  tongue  normally 
belong  to  the  fifth  nerve  (Fig.  237)  but  this  cannot  be  invariably 
be  depended  upon  as  both  sensory  and  taste  fibers  seem  subject  to 
some  variation.  Hartel  thinks  that  often  sensory  fibers  are  received 
through  the  carda  tympani,  which  communicates  with  the  seventh, 
thence  to  the  fifth  and  through  it  to  the  glossopharyngeal.  It  is 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND   FACE  621 

therefore  safer  in  blocking  the  anterior  part  of  the  tongue  to  inject 
the  lingual  nerve  at  the  inner  side  of  the  ramus  of  the  jaw,  and  for 
more  extensive  resections  the  technic  as  described  on  page  537  can  be 
followed.  Regarding  the  sense  of  taste,  Harris  has  found  it  to  be  ab- 
sent in  85  per  cent,  of  cases  of  ganglion  or  third  division  injection  and 
that  it  comes  on  immediately  and  is  coincident  with  anesthesia,  ex- 
tending as  far  back  as  the  circumvallate  papillae.  He  consequently 
draws  the  conclusion  that  in  the  large  majority  of  cases  taste  fibers 
from  the  tongue  reach  the  pons  through  the  third  division  of  the  fifth 
nerve  at  the  foramen  ovale,  and1  probably  reach  the  otic  ganglion 
through  the  small  superficial  petrosal  from  the  geniculate  ganglion  on 


a1 

csa 

nafc  Gr 


Fig.  238. — Instrumentarium  for  injection  of  gasserian  ganglion  (Windier,  Berlin): 
a,  Needle,  10  cm.  long,  0.8  mm.  thick.  Nickeled  steel  with  short  sharp  point  a1  and 
movable  gauge  a2;  b,  fine  needle  for  skin  anesthesia;  c,  2  c.c.  record  syringe;  d,  metal 
centimeter  measure  (reduced).  (Hartel.) 

the  facial,  thus  continuing  the  carda  tympani  fibers  serving  taste  sen- 
sation. In  the  minority  of  cases  (15  per  cent,  in  which  taste  is  not 
affected,  there  must  be  an  alternative  path  in  which  cases  it  seems 
probable  that  taste  sensations  are  continued  from  the  geniculate 
ganglion  to  the  gustatory  nucleus  in  the  medulla  through  the  pars 
intermedia  of  Wrisberg.  While  these  conclusions  are  not  accepted 
by  all  observers,  they  at  least  appear  reasonable  and  are  worthy  of 
record  here. 

In  5  cases  following  novocain  injections  there  was  pain  in  the 
head  for  several  days  following,  which  Hartel  attributes  to  an  aseptic 
meningitis,  and  in  i  case  reported  by  Hartel  there  was  a  septic 
meningitis;  the  termination  of  this  case  is,  however,  not  given.  This 
result,  he  believes,  due  to  the  use  of  a  solution  made  from  tablets, 


622  LOCAL    ANESTHESIA 

and  concludes  that  only  those  solutions  prepared  in  ampules  should 
be  used.  This  appears  to  me  as  hardly  the  explanation,  as  a  tablet 
solution  can  be  rendered  as  absolutely  sterile  as  when  prepared  in 
any  other  way.  This  is  of  interest  in  connection  with  the  fact  that 
recently,  in  English  literature,  appeared  a  report  of  extensive  slough- 
ing occurring,  following  the  use  of  an  old  but  re-sterilized  solution  of 
novocain,  which  result  was  repeated  when  again  tested  on  the  arm 
of  the  operator. 

Herpes  Facialis. — An  elderly  gentleman  was  referred  to  me  suf- 
fering from  an  unusually  aggravated  case  of  herpes  of  the  first  division 


.Fig.    239. — Result    of    removal  of    one-half    of    inferior    maxilla    under    regional 
anesthesia  for  malignancy.     (Case  of  Prof.  Matas.) 

of  the  fifth  nerve;  the  eye  was  much  inflamed  and  gave  him  con- 
siderable and  almost  constant  pain.  The  distribution  of  the  various 
branches  of  the  first  division  were  clearly  outlined  upon  the  side  of 
the  nose,  upper  lid,  forehead  and  scalp  as  far  back  as  the  occiput 
by  the  shrunken  condition  of  the  skin  which  alternated  in  color 
between  a  pale,  bloodless  white,  and  a  livid  red.  This  affected  area 
was  the  seat  of  an  almost  constant  burning  pain.  This  condition 
had  existed  for  eleven  months  and  had  practically  invalided  the 
patient.  Little  if  any  relief  had  been  obtained  from  the  various 
measures  which  had  been  applied.  The  case  had  come  to  me  for 
an  alcohol  injection  but  this  I  declined  to  do  for  obvious  reasons 


THE   HEAD,    SCALP,    CRANIUM,   BRAIN,    AND    FACE 


623 


but  suggested  that  I  inject  the  ganglion  with  cocain  in  salt  solution, 
hoping  by  this  procedure  to  obtain  some  physiological  readjustment 
of  the  trophic  cells  of  the  ganglion  in  much  the  same  way  that  the 
Cathelin  epidural  injections  accomplish  benefit  in  pelvic  neuroses. 
The  ganglion  was  injected  by  the  Hartel  route  with  ^  ounce  of 
normal  salt  solution  containing  ^  gr.  of  cocain.  There  was  imme- 
diate anesthesia  of  the  entire  anatomical  distribution  of  the  three 
branches.  With  the  subsidence  of  anesthesia  which  lasted  about 
one  hour.  There  was  some  recurrence  of  the  symptoms  in  the  scalp 
though  much  less  marked  than  before.  The  eye  began  to  improve 


Fig.  240. — Front  and  side  view,  showing  result  of  removal  of  one-half  of  inferior 
maxilla  for  malignancy.     (Case  of  Prof.  Matas.) 

immediately  and  in  a  few  days  was  apparently  normal  and  remained 
so.  While  it  is  hard  to  explain  just  what  such  an  injection  does 
that  accomplishes  good,  the  fact  remains  that  benefit  follows.  The 
same  principle  applied  elsewhere  will  naturally  suggest  itself  and  a 
spinal  puncture  might  be  tried  in  herpes  of  the  trunk. 

Any  peripheral  branch  of  the  fifth  nerve  may  be  injected  with 
impunity  under  the  guidance  of  certain  rules  and  technic.  But 
the  injection  of  the  gasserian  ganglion  is  not  always  an  easy  matter 
or  free  from  danger  of  after-effects;  it  should  consequently  not 
be  lightly  undertaken  and  should  never  be  done  when  peripheral 
injection  will  suffice  and  should  not  be  undertaken  by  the  inex- 
perienced except  after  careful  study  and  preparation. 


624  LOCAL   ANESTHESIA 

As  a  final  word  of  advice  for  making  deep  injections  into  the 
trunks  of  the  fifth  nerve  or  at  their  foramina  of  exit,  aside  from  the 
information  contained  in  the  preceding  pages,  it  will  be  found  of 
great  help,  as  suggested  by  Braun,  to  have  near-by  a  skull  set  in  the 
same  position  as  the  patient's  head  to  further  guide  one  in  the 
accurate  passage  of  the  needle, 


CHAPTER  XXIII 

THE  ORGANS  OF  SPECIAL  SENSE  WITH  DENTAL 
ANESTHESIA 

THE  EYE 

COCAIN  was  first  used  as  an  anesthetic  in  the  eye;  was  brought 
forward  by  Roller  in  his  epoch-making  announcement  in  1884. 
Although  many  other  agents  have  since  been  introduced,  each  having 
claims  in  one  or  the  other  direction,  still  cocain  remains  the  anesthetic 
of  choice  in  this  particular  field,  and  will  be  the  agent  considered  here 
in  discussing  the  various  ophthalmologic  operations. 

For  a  consideration  of  the  different  drugs  as  substitutes  for  cocain 
and  their  particular  advantages,  see  chapter  on  Local  Anesthetics. 
A  few  brief  remarks  regarding  the  use  of  cocain  in  a  general  way  will 
first  be  made. 

The  prolonged  or  repeated  use  of  cocain  in  the  eye  as  a  means  of 
controlling  pain  is  objectionable  on  two  grounds:  First,  the  haziness 
produced  in  the  superficial  cells  of  the  cornea  by  its  continued  action, 
made  worse  when  combined  with  the  use  of  coagulating  antiseptics, 
such  as  bichlorid  of  mercury  (see  chapter  on  Cocain) ;  and,  secondly, 
in  chronic  conditions  requiring  its  repeated  use,  in  the  hands  of  the 
patient,  may  lead  to  the  formation  of  a  habit.  The  first  objection 
raised  against  it  in  the  early  history  of  its  use  has  been  largely  over- 
come by  a  better  knowledge  of  its  action  gained  by  experience  leading 
to  its  more  judicious  and  skilful  use. 

The  slight  cloudiness  which  is  seen  to  follow  the  repeated  applica- 
tion of  cocain  to  the  cornea  was  first  observed  by  Koller;  this,  how- 
ever, clears  up  after  a  short  time,  but  is  most  marked  and  persistent 
when  bichlorid  of  mercury  is  used  as  a  cleansing  and  antiseptic  wash 
in  the  strengths  ordinarily  employed  (1:4000-6000). 

Koller  undertook  experiments  upon  rabbits  to  determine  the 
cause  of  this  action  ("Ref.  Hand  Book  Med.  Sci.,"  1901,  vol.  iii,  p. 
156).  Cocain  was  instilled  into  one  eye  and  the  lids  closed  and  held 
together  with  forceps ;  the  other  eye,  into  which  no  cocain  had  been  in- 
stilled, was  held  open  with  an  eye  speculum.  After  some  time  it  was 
observed  that  the  eye  held  open  showed  drying  and  loss  of  superficial 
epithelium,  while  the  cocainized  eye  showed  very  little  change;  from 
40  625 


626  LOCAL   ANESTHESIA 

this  it  was  concluded  that  the  hazy  changes  seen  to  occur  were  not 
due  solely  to  the  action  of  the  anesthetic.  His  views  on  this  point 
were  further  substantiated  by  other  observers. 

It  is  highly  useful  in  any  examination  of  the  eye,  where  pain,  pho- 
tophobia, and  lacrimation  would  otherwise  render  an  examination 
extremely  difficult,  if  not  impossible,  as  in  cases  of  conjunctival  or 
corneal  troubles,  superficially  situated  foreign  bodies,  injury  from 
chemical  irritants,  etc.  When  used  for  this  and  other  purposes  it  is 
better  to  make  several  applications  of  weak  solutions,  0.50  to  i  per 
cent.,  than  to  use  stronger,  4  to  5  per  cent,  solutions,  and,  where 
stronger  solutions  are  necessary  for  operative  purposes,  it  is  better  to 
precede  their  use  by  the  application  of  a  few  drops  of  a  weak  solution, 
as  the  contact  of  strong  solutions  produce  a  burning,  irritating  pain  of 
some  seconds'  duration  before  anesthesia  sets  in.  Its  use  for  pain 
which  might  possibly  be  of  glaucomatous  origin  should  be  carefully 
avoided,  as  it  has  repeatedly  been  proved  to  hasten  the  development 
of  a  threatened  glaucomatous  attack.  An  objection  raised  by  some 
operators  against  cocain  in  cataract  operation  is  that  it  renders  the 
eye  so  hypertonic  as  to  make  the  expression  of  the  cataract  more  dif- 
ficult; of  recent  years,  however,  this  objection  has  been  overcome  by 
more  skilful  methods,  and  its  use  has  many  advantages,  the  dilation 
of  the  pupil  making  iridectomy  unnecessary  by  avoiding  prolapse  of 
the  iris.  The  use  of  cocain  and  other  local  anesthetics  in  all  ophthal- 
mologic  operations  has  gradually  extended,  until  now  the  use  of 
general  anesthesia  has  been  reduced  to  a  minimum  and  by  some  is  al- 
most entirely  discarded. 

In  all  operations  upon  the  lids  a  triangular  or  crescentic  line  of 
infiltration  made  subcutaneously  with  0.25  to  0.50  per  cent,  solutions, 
with  or  without  adrenalin,  as  indicated,  will  block  off  the  operative 
area  and  secure  a  perfect  anesthesia  (Fig.  241). 

In  chalazion  a  light  infiltration  made  deep  under  the  subcutane- 
ous tissues  just  under  the  growth,  combined  with  one  or  two  applica- 
tions of  a  2  to  5  per  cent,  solution  over  the  region,  will  suffice  to  render 
the  field  anesthetic. 

While  all  operations  upon  the  conjunctiva  and  cornea  may  be 
made  perfectly  painless  by  instillations,  in  such  operations  in  which 
the  iris  is  to  be  handled  or  cut,  this  is  not  always  successful  by  instilla- 
tions alone,  and  when  used  it  is  necessary  to  use  strong  solutions,  4  to 
5  per  cent.,  and  begin  about  twenty  to  thirty  minutes  before  the  time 
for  operation,  instilling  a  few  drops  every  five  minutes,  allowing  it 
ample  time  to.be  absorbed  and  affect  the  deeper  parts.  During  this 


ORGANS    OF    SPECIAL   SENSE    WITH   DENTAL   ANESTHESIA 


627 


time  it  is  necessary  to  keep  the  eye  closed  to  prevent  evaporation  and 
drying  of  the  cornea.  The  difficulty  of  rendering  the  iris  absolutely 
anesthetic  by  this  method  led  surgeons  in  the  earlier  use  of  cocain  to 
inject  some  of  the  solutions  into  the  anterior  chamber  after  the  cor- 
neal  section,  a  method  which  has  now  been  almost  entirely  superseded 
by  the  subconjunctival  injection.  This  method  was  practised  by 
Roller  as  far  back  as  1885,  and  is  carried  out  as  follows:  After  several 
instillations  into  the  conjunctival  sac  to  render  this  and  the  cornea 
anesthetic,  a  speculum  is  inserted,  and  the  conjunctiva  seized  by 


Fig.  241. — Method  of  anesthesia  of  upper  eyelid.     (Braun.) 

means  of  a  mouse- tooth  forceps;  three  points  of  injunction  are  usually 
selected,  one  just  below  the  cornea  and  one  on  each  side  just  below 
the  middle  line;  it  is  necessary  that  these  sites  be  so  chosen  that  the 
resulting  edema  will  not  interfere  with  the  operation.  At  each  point 
2  drops  of  a  5  per  cent,  solution  are  injected,  care  being  taken  that 
the  needle  does  not  penetrate  into  the  subconjunctival  layers,  which 
would  result  in  too  much  edema.  After  these  injections  the  eye  is 
closed  for  five  minutes,  by  which  time  some  of  the  edema  subsides 
and  the  solution  has  been  given  time  to  act  and  the  iris  is  thoroughly 
anesthetic,  when  the  operation  may  be  undertaken. 

For  the  removal  of  cataract  several  instilla  tions  at  intervals  of  a 
few  minutes  of  a  5  per  cent,  solution,  keeping  the  eye  closed  during 
the  interval,  will  usually  suffice ;  but  when  it  is  necessary  to  handle  or 
operate  upon  the  iris,  these  instillations  should  be  supplemented  by 
subconjunctival  injections  of  2  to  5  per  cent,  solutions. 

For  operations  upon  other  parts,  tendons  or  muscles,  after  the 
preliminary  superficial  anesthesia',  the  conjunctiva  is  seized  with  for- 


628  LOCAL    ANESTHESIA 

ceps  just  over  the  point  of  operation,  and  the  point  of  the  needle  is 
inserted  as  deeply  as  possible  into  Tenon's  capsules  and  2  or  3  drops 
injected  at  the  point  of  the  intended  operation. 

The  eye  is  now  closed,  and  after  a  delay  of  five  to  ten  minutes  the 
tendons  can  be  painlessly  divided;  in  cases  where  it  is  necessary  to  ad- 
vance the  tendons  this  is  not  entirely  free  from  pain,  as  the  necessary 
pulling  on  the  central  and  deeper  parts  of  the  muscle  cause  pain,  as 
these  have  not  been  reached  by  the  anesthetic  solution. 

In  operations  upon  glaucoma,  acute  and  chronic,  Roller  recom- 
mends 5  per  cent,  solutions  of  cocain  containing  2  per  cent,  pilocarpin, 
and  states  that  after  an  experience  with  this  method  of  over  ten  years 
he  has  not  met  with  any  bad  effects  which  could  be  attributed  to  the 
injection,  and  the  results  obtained  compare  favorably  with  those  ob- 
tained by  any  other  method. 

Prof.  Koller,  in  speaking  of  the  action  of  cocain  as  a  mydriatic, 
as  well  as  its  use  in  certain  inflammatory  conditions,  states  the 
following : 

"  The  pupil-dilating  property  of  cocain  is  of  great  value  in  ophthal- 
moscopy.  While  the  dilatation  is  sufficient  in  the  dark  chamber  to 
allow  a  satisfactory  examination  it  does  not  have  the  blinding  effect 
of  belladonna,  the  pupil  all  the  time  responding  to  light. 

"This  is  due  to  the  fact  that  cocain  dilates  the  pupil  by  constrict- 
ing the  blood-vessels  of  the  iris,  but  leaves  the  sphincter  intact;  be- 
sides, the  accommodation  is  hardly  interfered  with. 

"The  pupil-dilating  power  of  cocain,  if  combined  with  that  of 
atropin,  is  invaluable  in  cases  of  iritis. 

"The  mydriatic  effect  of  this  combination  is  stronger  than  that 
of  any  other  drug  or  any  combination  of  drugs;  it  counteracts  both 
forces  that  contract  the  pupil,  the  sphincter  and  the  blood-vessels. 
(Hyperemia  of  the  iris  tends  to  contract  the  pupil  by  stretching  the 
tortuous  course  of  the  iris  arteries,  while  the  blood-vessels,  when 
empty,  return  to  their  tortuous  course  and  so  dilate  the  pupil.) 

"The  anemia  of  the  blood-vessels  is  a  strong  check  to  the  inflam- 
mation, the  pain  ceasing  mostly  after  a  few  installations  and  the  dura- 
tion of  treatment  being  greatly  shortened.  The  writer  uses  a  mixture 
of  equal  parts  of  a  i  per  cent,  solution  of  sulphate  of  atropin  and  a  5 
per  cent,  solution  of  hypochlorate  of  cocain;  at  first  he  instils  every 
ten  minutes  until  the  pupil  is  dilated  (three  to  four  instillations  are 
necessary),  then  only  three  times  a  day. 

"The  combination  of  the  two  drugs  is  also  efficient  in  cases  of 
cyclitis." 


ORGANS    OF    SPECIAL    SENSE    WITH    DENTAL   ANESTHESIA  629 

For  enucleation  it  is  necessary  to  carry  the  injection  deep  down 
around  the  origin  of  each  recti  muscle.  The  superficial  parts  are  first 
anesthetized  in  the  usual  manner  by  instillations  and  subconjuncti- 
val  injections,  combining  adrenalin  with  the  latter  as  well  as  with  the 
deeper  injections  around  the  recti  muscles,  using  not  over  i  or  2  drops 
of  i :  1000  adrenalin  at  each  point  of  injection,  making  use  of  a  2  to  5 
per  cent,  solution  of  cocain.  After  the  anesthesia  of  the  superficial 
parts  the  conjunctiva  is  divided  and  the  orbit  opened;  the  needle  is 
then  passed  deep  down  to  the  origin  of  each  recti  and  2  or  3  drops 
deposited  at  each  point;  when  this  has  been  completed  at  all  four 
points,  and  a  delay  of  a  few  minutes  allowed  for  thorough  saturation 
of  the  tissues,  the  anesthesia  should  be  complete  and  the  operation 
proceeded  with. 

The  advantages  of  combining  adrenalin  with  the  cocain  here  is 
decided  in  lessening  the  amount  of  hemorrhage  which  is  otherwise 
frequently  profuse,  as  well  as  prolonging  and  lessening  the  possibilities 
of  toxic  symptoms  arising  through  absorption.  Operators  differ  in 
their  views  regarding  the  advisability  of  the  use  of  adrenalin  in  other 
operations,  but  most  all  agree  that  it  is  of  advantage  in  such  opera- 
tions as  enucleation,  tenotomy,  and  advancement  of  the  tendons, 
where  it  both  intensifies  and  prolongs  the  anesthesia.  The  injection 
of  the  solution  into  the  insertion  of  the  tendons  is  not  desirable  as  it 
causes  too  much  swelling,  but  during  the  operation  pledgets  of  cotton 
wet  with  cocain  and  adrenalin  can  be  laid  upon  the  field. 

In  operations  for  pterygium  adrenalin  appears  to  be  contra-indi- 
cated, as  its  blanching  effect  renders  the  outline  of  the  growth  less 
distinct. 

In  the  removal  of  foreign  bodies  adrenalin  would  seem  contra- 
indicated,  except  where  the  hemorrhage  is  severe,  as  slight  hemor- 
rhage may  prove  of  benefit  by  washing  infectious  material  out  of  the 
wound,  which  might  otherwise  enter  the  deeper  tissues;  on  the  same 
grounds  cocain,  on  account  of  the  ischemia  it  produces,  might  prove 
objectionable  and  be  replaced  here  by  some  other  agent  which  does 
not  cause  such  vasoconstriction. 

As  a  general  thing,  adrenalin  should  be  very  cautiously  used  about 
the  eye ;  its  too  free  use,  or  too  strong  solution,  may  give  rise  to  an  aching 
pain  or  produce  disturbances  in  the  cornea.  When  used  by  instilla- 
tion it  should  not  exceed  a  few  drops  of  a  i :  10,000  to  15,000  solution. 

In  all  operations  upon  the  eye  with  cocain  care  should  be  exer- 
cised, as  idiosyncrasies  are  frequently  encountered  and  may  give  rise 
to  unpleasant  and  often  toxic  symptoms. 


630  LOCAL   ANESTHESIA 

For  a  diagram  of  the  nerves  of  the  eye,  see  Fig.  172,  and  for  a 
further  description  of  the  anatomy  of  these  parts,  see  chapter  on  the 
Head.  In  addition  to  the  above,  two  special  methods  of  anesthesia 
are  frequently  employed  for  enucleation,  the  methods  of  Lowenstein 
and  Siegrist. 

Lowenstein  anesthetizes  the  ciliary  ganglion  and  retrobulbar  struc- 
tures by  a  retrobulbar  infiltration.  After  first  anesthetizing  the  con- 
junctiva by  infiltration,  a  point  on  the  outer  orbital  margin  is  selected 
and  a  long,  fine  needle  entered  at  this  point  and  passed  obliquely  in- 
ward and  backward  behind  the  bulb  (see  "Anatomy  of  the  Orbit"  in 
chapter  on  the  Head) ,  injecting  the  solution  as  the  needle  is  advanced 
until  a  depth  of  about  4^  cm.  has  been  reached.  Care  is  exercised 
not  to  puncture  the  bulb  by  displacing  it  inward  with  the  finger  and 
by  a  lever-like  motion  of  the  needle  to  determine  that  it  is  free  in  the 
retrobulbar  space;  at  this  point  from  i  to  2  c.c.  of  a  i  per  cent,  cocain 
solution  is  injected. 

In  the  method  of  Siegrist  the  same  purpose  is  accomplished  by 
using  curved  needles,  which  are  passed  through  the  conjunctiva  from 
four  puncture  points  around  the  margin  of  the  orbit  and  passed 
around  the  bulb  into  the  retrobulbar  tissues. 

THE  EAR 

From  a  study  of  the  nerve  supply  of  the  auricle  it  will  be  seen  that 
a  horseshoe-shaped  injection,  embracing  the  ear  from  below,  made 
subcutaneously  and  carried  down  beneath  the  attachment  of  the  deep 
fascia  to  the  bone,  will  reach  and  block  the  entire  nerve  supply  to 
these  external  parts,  or  the  procedure,  as  illustrated  in  Fig.  242,  may 
be  adopted. 

Where  the  operative  field  involves  the  external  parts  of  the  audi- 
tory canal  supplied  by  the  auricular  branch  of  the  pneumogastric  an 
injection  should  be  made  deep  at  the  root  of  the  ear,  on  its  posterior 
aspect,  where  this  branch  of  the  pneumogastric  passes  upward  and 
forward  through  the  auricular  fissure  between  the  mastoid  process 
and  the  auditory  canal. 

This  simple  procedure  will  permit  of  any  operation  on  the  exter- 
nal parts.  Solution  No.  i  will  be  found  sufficiently  strong  for  this 
purpose;  the  addition  of  adrenalin  will  render  the  field  completely 
ischemic.  In  exceptional  conditions  of  great  vascularity,  a  proced- 
ure, used  by  Prof.  Matas  and  reported  in  the  following  case,  will  be 
found  of  great  value : 

"The  utility  of  Coming's  principle  of  incarceration  was  most 


ORGANS    OF    SPECIAL   SENSE   WITH   DENTAL   ANESTHESIA 


631 


forcibly  impressed  upon  my  mind  in  1890  in  operating  upon  an  ex- 
tremely vascular  nevoid  angioma  of  the  entire  auricle. 

"In  this  case  the  ear  presented  elephantine  proportions,  and  pul- 
sated with  the  arterial  and  venous  blood  by  enormously  dilated  blood- 
vessels; one  of  the  cayerns  ruptured  by  ulceration  and  the  patient 
nearly  succumbed  after  a  frightful  hemorrhage.  The  external 
carotid  was  ligated,  but  this  was  followed  by  only  temporary  im- 
provement. A  few  weeks  afterward  the  ear  was  cocainized,  resected, 
and  bared  completely  of  its  tegumentary  covering,  including  the 
afferent  blood-vessels,  which  were  all  secured  and  ligated  by  a  very 


Fig.  242. — Points  of  injection  for  anes- 
thetizing external  ear.     (Braun.) 


Fig.  243. — Van  Eicken's  method  of 
injection  for  anesthetizing  external  audi- 
tory canal.  (Braun.) 


simple  procedure.  This  consisted  in  the  injection  of  a  4  per  cent, 
solution  of  cocain  (0.50  to  i  per  cent,  would  have  been  sufficient) 
into  the  peri-auricular  tissues  at  the  root  of  the  ear,  until  a  com- 
plete circle  of  cocain  solution  had  been  formed  around  it.  Four 
hair-lip  pins  were,  then  introduced  at  equidistant  points,  so  as  to 
transfix  sections  of  the  circle.  There  were  used  as  binding  posts  to 
hold  a  thin  rubber  band,  which  was  wound  around  each  pin,  and  the 
rubber  was  stretched  tightly  around  the  pedicle.  The  pulsations 
in  the  ear  ceased  immediately,  and,  with  the  arrested  circulation,  a 
complete  anesthesia  of  the  auricle  followed,  which  permitted  the 
operation  to  be  performed  throughout  without  pain  or  hemorrhage." 
For  the  anesthesia  of  the  external  auditory  canal  and  tympanum, 
many  operators  in  this  field  have  worked  out  various  plans  by  which 
operations  on  these  parts  may  be  painlessly  performed. 


632  LOCAL   ANESTHESIA 

Von  Eicken  suggests  the  following: 

For  external  parts  he  begins  by  spraying  with  ethyl  chlorid,  and 
then  follows  with  an  injection  of  cocain  and  adrenalin  solution  in  the 
posterior  fold  of  the  pavilion,  under  the  cartilage  of  the  floor  of  the 
canal.  The  needle  is  directed  upward  and  backward  to  reach  the 
point  of  emergence  of  the  auricular  branch  of  the  pneumogastric, 
which  is  the  sensory  nerve  of  the  posterior  part;  without  completely 
withdrawing  the  needle,  the  point  is  then  forced  toward  the  anterior 
and  deeper  part  of  the  canal  to  attain  the  auriculotemporal  filaments 
(Fig.  243). 

Complete  anesthesia  of  the  external  canal  is  thus  obtained  in  one 
or  two  minutes.  The  tympanum  is  next  anesthetized  by  injecting 
the  solution  into  the  skin  of  the  deeper  part  of  the  canal. 

While  the  above  may  prove  successful,  it  has  not  appeared  to  us 
that  the  use  of  ethyl  chlorid  about  the  external  auditory  canal  was 
very  satisfactory,  as  its  application  here  has  seemed  unpleasant  to 
the  patient. 

The  following  plan  by  Tiefenthal  appeals  to  us,  and  is  equally 
simple;  a  combination  of  the  two,  by  injecting  the  auditory  branch 
of  the  pneumogastric  as  recommended  above,  followed  by  anesthesia 
of  the  drum  as  practised  by  Tiefenthal,  may  prove  more  satisfactory. 

Tiefenthal  recommends  that  4  drops  of  a  20  per  cent,  solution  of 
cocain  with  i  drop  of  adrenalin  (i  :  1000)  be  placed  in  contact  with 
the  drum  membrane  for  fifteen  minutes.  This  produces  a  slight 
reduction  of  sensibility,  but  insufficient  for  paracentesis.  Then, 
with  a  small  syringe  having  a  fine,  angular  needle,  he  injects  through 
the  lower  part  of  the  membrane  2  to  4  drops  of  a  5  or  10  per  cent, 
solution  of  cocain  with  adrenalin.  After  a  few  seconds  the  mem- 
brane appears  whitish  gray  from  the  anemia  of  the  tympanic  cavity, 
the  anesthesia  is  complete,  and  paracentesis  may  be  performed 
without  pain  or  hemorrhage. 

Professor  Neumann,  who  has  done  much  work  with  local  anes- 
thesia on  the  ear,  secures  anesthesia  in  much  the  same  way.  The 
operative  possibilities  are  not,  however,  limited  to  these  simple 
procedures,  mastoid  operations  being  performed  with  equal  success. 
For  this  purpose  it  is  necessary  to  have  a  strong  syringe.  Neu- 
mann used  a  metal  syringe  with  specially  modified  needle,  but  any 
strong  syringe  and  needle  will  do.  He  recommends  a  i  per  cent, 
eucain  solution,  with  5  drops  of  tonogen  (an  Austrian  preparation 
of  adrenalin)  to  each  cubic  centimeter  for  infiltration  of  the  soft 
parts.  The  deeper  infiltration  about  the  periosteum  is  done  with  a 


ORGANS    OF    SPECIAL   SENSE    WITH   DENTAL   ANESTHESIA 


633 


i  per  cent,  solution  of  cocain  and  5  drops  of  tonogen  to  each  cubic 
centimeter.  The  solutions  are  warmed  before  injection  to  about 
45°C.  to  facilitate  their  diffusion. 

The  entire  region  over  the  mastoid  is  now  thoroughly  injected 
subcutaneously  with  the  eucain  solution,  from  the  base  to  the  apex 
and  forward  to  the  ear  (Fig.  244) ;  some  of  the  solution  is  then  injected 
subperiosteally;  the  ear  is  now  drawn  forward,  and  the  anterior  wall 
of  the  mastoid  process  injected  subperiosteally  down  to  the  bony 
termination  of  the  auditory  canal  (Fig.  245). 

Through  a  speculum,  which  is  now  inserted  into  the  ear,  i  c.c.  of 


Fig.  244. — Points  of  injection  for  sur- 
rounding operative  field  with  zone  of  anes- 
thesia for  mastoid  operation.  (Braun.) 


Fig.  245. — Point  for  deep  injection 
behind  ear.     (Braun.) 


the  cocain  solution  is  injected  into  the  superior  wall  of  the  auditory 
canal,  at  the  point  of  junction  of  the  bony  and  cartilaginous  portions, 
another  syringeful  into  the  inferior  wall,  and  slightly  less  into  the 
anterior  and  posterior  walls.  These  injections  must  be  made  beneath 
the  periosteum,  and  in  such  a  manner  that  they  produce  a  distinct 
bulging  or  protrusion,  which  disappears  as  absorption  takes  place. 
A  small  pledget  of  cotton,  saturated  with  20  per  cent,  cocain  solu- 
tion, is  now  inserted  into  the  tympanic  cavity  through  the  perfora- 
tion in  the  tympanic  membrane  (which  always  exists  in  these  cases) . 
This  is  not  removed  until  the  antrum  is  opened  during  the  progress 
of  the  operation. 

After  a  delay  of  about  fifteen  minutes  the  operation  may  be 
begun.     It  is  recommended  that  in  cutting  the  bone  only  a  very 


634  LOCAL   ANESTHESIA 

sharp  chisel  should  be  used,  which  is  held  as  flat  as  possible  and  the 
bone  shaved  off  in  this  manner,  and  never  holding  the  chisel  perpen- 
dicular, which  would  produce  too  much  concussion  and  would  be 
very  trying  to  a  conscious  patient.  If  preferred,  a  burrow  or  other 
drilling  instruments  may  also  be  used.  While  the  above  description 
is  for  the  regular  mastoid  operations,  it  is  by  no  means  limited  to  this 
class  of  cases,  but  may  be  used  equally  as  well  in  acute  mastoiditis. 

NOSE  AND  THROAT 

The  present-day  operator  little  conceives  of  the  difficulties  ex- 
perienced in  certain  departments  of  surgery  in  the  days  before  the 
introduction  of  cocain  and  its  congenors,  even  after  we  had  the 
many  benefits  conferred  by  general  anesthesia.  As  illustrative  of 
these  conditions,  and  the  efforts  many  were  making  toward  finding 
suitable  local  anesthetics,  I  quote  the  following  by  Dr.  Wm.  C.  Glas- 
gow, of  St.  Louis,  read  before  the  American  Laryngological  Society 
at  New  York,  1879.  The  same  difficulties  were  experienced  in  all 
fields  of  work  where  local  anesthetics  are  now  so  freely  used. 

"The  need  of  an  agent  by  which  the  excessive  sensibility  and  the 
spasmodic  contractions  of  the  larynx  caused  by  the  introduction  of 
instruments  can  be  controlled  has  been  fully  experienced  by  every 
laryngeal  surgeon. 

"The  common  method  of  deadening  sensibility  by  the  repeated 
introduction  of  the  sound  is  tedious  both  to  operator  and  patient. 
Some  cases  can  be  readily  operated  upon  with  slight  preparation, 
but  still  we  find  others  where  the  most  persistent  education  gives 
little  result. 

"The  use  of  bromids,  potassium,  sodium,  and  ammonium,  when 
applied  locally  and  taken  internally,  produce  a  certain  effect  in 
diminishing  the  sensibility,  but  their  use  is  unsatisfactory  when  the 
production  of  anesthesia  of  the  larynx  is  desired.  The  same  may  be 
said  of  ice  and  the  various  astringents,  as,  for  example,  tannin.  The 
morphin  and  chloroform  solution  of  Prof.  Bernatzic,  given  by  Turch 
and  as  used  by  Bruns  and  Schroetter,  does  certainly  produce  the 
desired  result,  but  as  the  constitutional  effects  of  morphin  are  marked 
long  before  the  anesthesia  of  the  larynx  is  sufficient  it  cannot  be 
regarded  as  a  safe  remedy  or  one  that  can  come  into  general  use. 

"In  1871,  fresh  from  the  instruction  of  the  Vienna  school,  I  used 
this  solution  for  the  first  and  I  trust  for  the  last  time.  The  patient 
was  a  young  girl,  with  papillomata  of  the  larynx.  I  applied  the 
solution  of  Bernatzic  after  the  manner  taught  by  Schroetter.  The 


ORGANS   OF    SPECIAL    SENSE    WITH   DENTAL  ANESTHESIA  635 

constitutional  symptoms  preceded'  the  local  anesthesia  fully  one 
and  one-half  hours,  and  they  became  so  grave  during  the  operation 
that  it  had  to  be  suspended  and  the  most  energetic  measures  em- 
ployed to  combat  the  toxic  efforts  of  the  drug.  The  local  anesthesia, 
however,  was  complete. 

"I  have  seen  the  morphin  solution  repeatedly  used  with  great 
success  in  the  Vienna  clinic,  and  it  may  be  possible  that  my  patient 
was  peculiarly  susceptible  to  the  drug;  still,  the  method  is  subject  to 
too  many  risks  ever  to  become  popular. 

"During  the  past  winter  I  have  been  experimenting  with  two 
remedies,  both  of  which  produce,  in  a  measure,  not  only  the  desired 
anesthesia,  but  also  relief  from  pain.  I  refer  to  hydrate  of  chloral 
and  carbolic  acid.  Both  remedies  have  been  extensively  used  in 
throat  practice,  but,  as  far  as  I  am  aware,  they  have  never  been 
suggested  or  used  for  the  purpose  of  producing  anesthesia  of  the 
larynx,  etc." 

The  above  gives  a  brief  idea  of  earlier  difficulties  encountered 
and  the  efforts  made  by  the  pioneer  operators  in  their  search  for  a 
satisfactory  local  anesthetic;  up  to  the  very  time  of  the  discovery  of 
cocain  this  search  had  gone  ceaselessly  on;  the  literature  of  the 
precocain  period  is  full  of  similar  reports,  and  many  different  measures 
utilized  to  produce  what  was  unsatisfactory  local  analgesia. 

,  In  ophthalmology,  nose  and  throat  surgery,  and  to  the  surgeon 
specialist  local  anesthesia  has  proved  a  great  boon,  reducing  to  simple 
office  procedures  many  operations  which  formerly  required  a  sojourn 
in  an  institution  and  a  general  anesthetic  for  their  performance. 
The  use  of  such  instruments  as  sounds  and  dilators,  is  now  done 
away  with,  where  the  parts  can  be  readily  anesthetized.  The  ex- 
amination of  sensitive  and  inflamed  parts  can  also  be  carried  out 
without  the  discomfort  to  the  patient  formerly  necessary.  Not- 
withstanding the  many  advances  in  local  anesthesia  during  the  last 
few  years,  and  the  newer  and  safer  agents  introduced,  cocain  still 
remains  the  anesthetic  of  choice  among  the  great  majority  of  operators 
in  these  special  fields.  This  is  no  doubt  due  to  the  fact  that  cocain, 
being  the  first  agent  introduced,  the  methods  of  application  necessary 
to  its  success  have  been  studied  and  perfected,  until  now  it  is  hard 
to  displace  it  from  its  firmly  established  position.  However,  we 
are  firmly  convinced  that  the  time  and  trouble  required  to  under- 
stand the  slight  differences  necessary  in  technic  of  the  use  of  some 
of  the  safer  agents,  particularly  novocain,  to  insure  the  same  degree 
of  anesthesia  will  be  more  than  amply  repaid  by  the  occurrence  of 


636  LOCAL    ANESTHESIA 

fewer  sequelae  and  toxic  symptoms.  For  this  reason,  we  especially 
urge  the  reader  to  consider  carefully  the  description  of  these  different 
agents  described  in  the  chapter  on  Local  Anesthesia,  and  that  part 
of  the  chapter  on  Technic,  dealing  with  the  action  of  concentrated 
and  weak  solutions  as  it  is  particularly  applicable  to  nose  and  throat 
surgery.  In  our  discussions  here  we  will  follow  the  trend  of  the 
present  time  and  describe  the  operative  procedures  under  cocain. 

It  is  not  alone  in  operative  work  that  local  anesthesia  may  prove 
of  value  in  this  field,  as  it  may  be  used  to  advantage  in  a  certain 
limited  number  of  cases  in  a  diagnostic  way;  in  reflex  neurosis,  start- 
ing from  the  nose,  the  exact  location  of  the  trouble  can  often  be 
definitely  determined,  as  an  application  of  cocain  to  the  starting- 
point  relieves  the  reflex  (asthma,  etc.). 

There  are  three  methods  of  applying  cocain  to  these  parts  in 
common  use — by  sprays,  swabs,  and  infiltration  (cataphoresis  rarely). 
In  using  a  spray  it  is  advisable,  as  a  rule,  to  use  only  weak  solutions 
(2  per  cent.)  in  graduated  bottles,  so  that  the  exact  quantity  used 
may  be  definitely  known,  to  avoid  the  possibility  of  poisoning. 
Having  the  patient  to  expectorate  any  accumulations  in  the  mouth 
or  pharynx  instead  of  swallowing  them.  Weak  solutions,  applied 
repeatedly  at  intervals  of  a  few  minutes,  will  accomplish  as  much 
as  stronger  ones  and  eliminate  dangerous  possibilities;  the  first  appli- 
cation, by  constricting  the  blood-vessels,  produces  a  certain  degree 
of  ischemia  when  subsequent  applications  upon  the  ischemic  area 
act  more  profoundly  and  absorption  is  greatly  lessened.  For  appli- 
cation with  a  swab  stronger  solutions  are  advisable,  5,  10,  or  15 
per  cent.,  although  many  operators  use  highly  concentrated  solutions 
up  to  50  per  cent.,  as  will  be  spoken  of  later. 

For  application  to  the  larynx  it  is  usually  advisable  to  use  solu- 
tions of  at  least  20  per  cent.  For  infiltration  it  is  usually  necessary 
to  use  from  0.50  to  2  per  cent,  solutions. 

Adrenalin  plays  an  active  part  in  nearly  all  these  applications,  but 
it  should  be  cautiously  used,  as  it  is  an  agent  capable  of  producing 
considerable  disturbance,  and  many  symptoms  erroneously  attributed 
to  the  anesthetic  are  in  reality  due  to  the  adrenalin.  In  this  respect, 
it  may  be  said  that  it  often  produces  a  peculiar  tight  feeling  or  pain 
in  the  head  when  too  freely  or  injudiciously  used. 

The  advisability  of  administering  to  all  patients  about  to  undergo 
an  operation  of  any  severity  upon  these  parts  some  preliminary 
sedative  a  short  while  before,  the  same  as  is  advocated  for  any 
general  surgical  procedure  under  purely  local  means,  has  been  dis- 


ORGANS    OF    SPECIAL    SENSE    WITH    DENTAL   ANESTHESIA  637 

cussed  by  rhinologists.  The  objections  found  with  the  usual  morphin 
and  scopolamin  is  that  most  of  these  patients  are  operated  in  the 
sitting  position,  and  while  the  medication  accomplished  the  desired 
end  in  relieving  anxiety  and  uneasiness,  it  often  makes  the  patients 
so  drowsy  that  they  nod  about  and  are  unsteady  in  the  chair. 
Leshure  makes  use  of  the  following,  which  is  given  by  mouth  about 
one-half  hour  before  operation — morphin,  34  gr.;  hyoscin  hydro- 
bromatic,  >f0o  gr.;  and  strychnin  sulphate,  ^0  gr.,  which  is  prac- 
tically equivalent  to  our  morphin  and  scopolamin,  with  the  addition 
of  the  strychnin. 

Miller  recommends  the  following — sodium,  potassium,  and  am- 
monium bromid,  aa  10  gr.;  spiritus  ammoniae  aromaticus,  i  dram; 
aqua  q.  s. ;  this  is  given  a  short  while  before  operation. 

If  nausea  occurs  during  the  progress  of  the  operation  it  is  usu- 
ally relieved  by  the  inhalation  of  ammonia,  and  with  any  evidence  of 
faintness  the  head  should  at  once  be  lowered. 

In  operations  upon  the  anterior  end  of  the  nose  in  such  procedures 
as  the  removal  of  dislocated  septal  cartilages,  infiltration  is  usually 
necessary,  using  0.50  to  i  per  cent,  solutions  of  cocain  with  adrenalin, 
injecting  the  solution  beneath  the  skin  and  mucous  membrane 
surrounding  the  field  sufficient  to  produce  a  moderate  degree  of 
edema,  and  allowing  a  few  minutes  to  elapse  before  beginning  the 
operation. 

A  somewhat  similar  technic  can  be  followed  in  dissecting  out 
portions  of  the  lateral  cartilages,  when  these  encroach  upon  the 
breathing  space;  the  injection  is  made  beneath  the  skin  and  mucous 
membrane,  particular  attention  being  paid  to  the  region  of  the 
nasopalatine  nerves,  for  if  these  are  not  rendered  anesthetic  pain 
will  be  complained  of  in  the  front  teeth  when  those  nerves  are 
reached. 

In  the  anesthetization  of  those  parts  of  the  nasal  tract,  septum, 
and  turbinates,  which  are  usually  accomplished  by  swabbing  the 
operative  area,  many  operators  of  extensive  experience  and  un- 
doubted ability  prefer  to  make  use  of  very  strong  solutions,  some- 
times reaching  50  per  cent,  and  stronger,  ra.ther  than  follow  the 
example  of  the  general  surgeon,  whose  aim  is  constantly  to  reduce 
the  concentration  of  the  solutions  used  to  the  minimum  effective 
strengths.  It  would  seem  to  us  advisable  to  use  repeated  applica- 
tions of  weaker  solutions  rather  than  such  concentrated  strengths, 
but  the  use  of  the  strengths  in  this  especial  field  is  not  without  a 
rational  basis  founded  upon  physiologic  laws,  as  is  discussed  in  the 


638  LOCAL   ANESTHESIA 

chapter  on  Principles  of  Technic.  The  merit  of  the  procedure  is 
further  borne  out  by  the  constantly  accumulating  clinical  evidence 
and  the  skill  and  ability  of  those  making  use  of  these  practices. 
Some  operators,  when  operating  upon  these  parts  by  means  of  the 
swab,  prepare  their  solution  by  placing  a  few  grains  of  pure  cocain 
crystals  in  a  dish  or  suitable  receptacle  and  moistening  them  with 
just  enough  adrenalin  (i  :  1000)  to  render  them  soluble,  claiming 
better  results  from  this  solution,  which  gives  an  anesthesia  of  from 
three-quarters  to  one  hour  duration. 

In  operations  upon  the  septum  and  turbinates  two  methods  of 
inducing  anesthesia  are  in  vogue:  By  packing  the  nasal  cavity  with 
pledgets  of  cotton,  wet  in  the  anesthetic  solution,  and  allowing  them 
to  remain  for  about  twenty  minutes ;  this  may  be  supplemented  later, 
if  found  necessary,  by  a  light  application  with  the  swab.  The  objec- 
tion of  this  method  of  packing  is  that  large  quantities  of  cocain  are 
likely  to  be  absorbed,  as  the  packs  come  in  contact  with  the  entire 
nasal  fossa  and  their  presence  stimulates  the  flow  of  mucus,  which 
washes  the  cocain  down  into  other  parts  where  absorption  takes 
place.  A  much  safer  and  better  method  is  to  anesthetize  the  field 
by  the  use  of  swabs,  and  here  much  skill  can  be  shown  in  their  use; 
in  beginning  the  application  of  a  swab  upon  sensitive  parts  it  can 
always  be  preceded  by  the  use  of  the  spray;  after  the  swab  has  been 
applied,  allow  it  to  remain  in  position  a  few  moments;  as  the  anes- 
thetic is  taken  up  it  diffuses  in  all  directions,  which  can  be  recog- 
nized by  the  blanching  effect  upon  the  tissues;  the  application  is  then 
reapplied  within  the  margin  of  this  area  in  much  the  same  way  as  a 
skilful  surgeon  will  infiltrate  the  skin;  in  this  way  the  patient  is  not 
conscious  of  pain  or  other  discomfort  during  the  anesthetizing 
process. 

Special  attention  should  be  paid  to  any  irregularities,  such  as 
spurs  and  deviations,  to  insure  reaching  all  overhanging  or  posterior 
surfaces,  by  bending  the  applicators  in  suitable  directions.  An 
applicator  once  used  should  not  again  be  placed  in  the  solution,  as 
mucus  and  other  secretions  carried  in  with  it  dilute  the  solution. 

The  utilization  of  regional  methods  of  anesthesia  has  a  limited 
application  within  the  nose,  by  swabbing  the  solution  in  concen- 
trated form  over  the  trunks  of  the  nerves  at  their  points  of  emergence 
upon  the  nasal  septum.  Some  few  operators  recommend  injecting 
the  solution  at  these  points,  and  while  this  may  in  rare  instances  be 
necessary,  as  in  the  case  of  extensive  scar  formation  or  other  condi- 
tions, the  majority  of  operators  find  the  swab  sufficient,  as  the  solu- 


ORGANS    OP    SPECIAL    SENSE    WITH   DENTAL   ANESTHESIA 


639 


tion  readily  penetrates  the  overlying  mucous  membrane  and  reaches 
in  effective  strength  the  underlying  nerves.  (See  discussion  of  the 
use  of  concentrated  solutions  upon  mucous  surfaces  in  chapter  on 
Principles  of  Technic.) 

By  a  study  of  the  accompanying  illustrations,  showing  the  course 

apt.  ethmoidal  artery 


spf, 


cribriform  plate     post,  ethmoidal  i*^'' 

post. art.  ot  nasal     \       artery 
nasopatatine  nerve    septum  (sphe-  N    • 
'icnoid  bone  >      *\  \   "°Paia'-J      \   \< 


Qnterior  ethmoidal  nerve 

anterior  meningeal  art.    X 

'dory  nerves 
(medial) 
anter.  art.  of 
nasal  septum 

I/  br.  of 
at.  tthm.  nerve* 


tandibula  x 
Mylohyoideus  X 


•7       /  r»      ,      Aiyionyoiaeu 

I;       /  /       (jtniohyoirteus  x 

';      /  liypoglossnl  nerve  X 

/      deep  lingual  art. 


Fig.  246. — The  nerves  and  arteries  of  the  nasal  septum  and  of  the  tongue.     *  =  divided 
posterior  pharyngeal  wall    **  =  sphenoidal  sinus.     (Sobotta  and  McMurrich.) 

and  distribution  of  the  nerve  supply,  a  knowledge  of  regional  methods 
here  is  readily  obtained  (Figs.  246-250). 

The  presence  of  scar  tissue  occasionally  found  in  the  septal 
mucosa,  the  result  of  previous  disease  (small-pox,  etc.)  or  injury, 
may  render  the  production  of  perfect  anesthesia  by  means  of  appli- 


640 


LOCAL    ANESTHESIA 


cators  impossible.     In  such  cases  resort  must  be  had  to  infiltration; 
this  however,  is  rarely  necessary. 

When  using  infiltration,  Killian  recommends  a  regional  anesthesia 
blocking  the  septal  nerves.  He  makes  the  injection  at  two  points 
— (i)  just  anterior  to  the  tuberculum  septi  in  an  upward  direction, 


lesser  palatine  art. 


poster,  lateral 
""sal  nerves 


posterior  lateral  nasal  arteries 
jf     olfactory  nerves  (lateral) 

/  4 


anterior  nasal  br.  oj 
(i/it.  ethmoid,  nerve 


terior  lateral  nasal  art. 
asal  concha 


\opHaryngeul  nerve       \    .         ..   .      ,  -  ,.;.       ,  \ 

,  ton-    lingual  •     vallate     lingual    , 
scendtng  P°  at(»e  art.  .  sil,    brancll    -,  papinae  follicles    \ 


tonsillur  or. 


"palatine  tonsil 


\    inaudible  X 
'i         dorsum  of  tongue 
fereat  palatine  art. 
ant.  palatine  nerve 


Fig.  247. — The  nerves  and  arteries  of  the  outer  nasal  wall  and  of  the  palate.  The 
tongue  has  been  drawn  out,  all  of  the  nasal  septum  except  its  lower  portion  removed,  and 
the  mucous  membrane  of  the  faucial  isthmus  divided  along  the  glossopharyngeal  nerve 
and  the  ascending  palatine  artery.  **  =  Sphenoidal  sinus.  *  =  Divided  branches  to 
nasal  septum.  ***  =  Anastomosis  between  nasopalatine  and  anterior  palatine  nerves. 
*  +  =  mucous  membrane  of  hard  palate.  (Sobotta  and  McMurrich.) 

and  (2)  at  a  point  just  below  the  middle  of  the  lower  border  of  the 
middle  turbinate  (Fig.  250). 

The  Inferior  Turbinate. — This  is  anesthetized  in  much  the  same 
way  as  the  septum,  except  that  greater  difficulties  are  usually 
encountered,  particularly  when  it  is  large,  overhanging,  and  en- 


ORGANS    OF    SPECIAL    SENSE    WITH    DENTAL    ANESTHESIA  641 


Fig.    248. — Innervation  of  nasal  septum.  Fig.  249. — Inner vation  of  lateral  nasal 

(Braun.)  wall:     /,     Olfactory     nerve;    II,    nasal 

nerve;  ///,  nasopalatine  nerve.     (Braun.) 


opalat 


Fig.  250. — Points  of  anesthesia  for  Killian  regional  method.     (Braun.) 
41 


642  LOCAL   ANESTHESIA 

croaching  upon  the  surrounding  parts;  however,  the  application  of 
the  cocain-adrenalin  solution  soon  produces  a  certain  amount  of 
shrinkage,  making  the  concealed  parts  more  accessible.  At  times 
it  is  necessary  to  reach  the  posterior  parts  by  using  a  curved  ap- 
plicator passed  from  behind  through  the  nasopharynx.  Rarely 
is  it  found  necessary  to  use  infiltration,  and  when  this  is  done  great 
care  should  be  exercised  as  the  absorptive  power  of  this  tissue  is 
tremendous. 

The  middle  turbinate  is  usually  much  simpler,  and  is  treated  in 
much  the  same  manner. 

The  nasofrontal  duct  and  antrum  of  Highmore  are  operated  upon 
in  the  same  manner  by  securing  anesthesia  by  the  use  of  swabs  over 
the  surfaces  to  be  operated  upon. 

The  uvula  presents  no  difficulties,  and  is  easily  anesthetized  by 
a  few  applications  with  the  swab  or  it  can  be  infiltrated. 

The  lingual  tonsil  presents  some  difficulties,  and  should  be  anes- 
thetized with  great  care,  particularly  if  the  cautery  is  to  be  used. 
As  cocain  is  destroyed  by  heat,  it  is  necessary  to  have  the  anesthesia 
penetrate  well  beyond  the  influence  of  the  cautery,  passing  the 
swabs  well  down  to  its  base  between  the  folds  of  the  lymphoid 
tissue. 

The  nasopharynx  is  ordinarily  rather  difficult  of  operation  under 
local  anesthesia,  largely  due  t6  its  being  rather  difficultly  accessible, 
and  to  its  being  covered  in  these  cases  with  tenacious  mucus  which 
protects  the  underlying  membrane.  However,  certain  operations 
can  be  very  satisfactorily  performed.  The  anesthesia  is  accomplished 
by  swabs  passed  back  through  the  nose  on  each  side  and  up  through 
the  mouth;  during  this  procedure  care  should  be  exercised  not  to 
overlook  the  posterior  border  of  the  septum. 

The  ordinary  curet  is  unsatisfactory  for  operations  under  local 
anesthesia,  as  the  blade  wounds  the  deeper  structures,  which  have 
been  only  imperfectly  anesthetized;  instead  resort  should  be  had  to 
such  instruments  as  the  Schultz  adenotome,  which  are  so  constructed 
as  to  protect  the  deeper  parts. 

The  Faucial  Tonsil. — This  structure,  on  account  of  its  ready  acces- 
sibility, is  ordinarily  quite  easily  enucleated  under  local  anesthesia, 
different  operators  using  different  methods  of  anesthesia  and  various 
anesthetic  solutions;  recently  some  have  advocated  quinin  and 
urea,  on  account  of  the  absence  of  after-pain  under  its  use  and  the 
diminished  tendency  to  postoperative  hemorrhage. 

From  our  personal  experience  with  this  agent  we  would  not  care 


ORGANS    OF   SPECIAL   SENSE    WITH  DENTAL   ANESTHESIA 


643 


to  recommend  it  as  it  is  at  present  used.  (See  chapter  on  Quinin  and 
Urea.)  The  anesthetizing  process  is  begun  by  brushing  the  tonsil, 
its  anterior  and  posterior  pillars,  and  supratonsillar  fossa  with  a 
swab  wet  in  a  strong  10  to  20  per  cent,  solution  of  cocain  and 
adrenalin.  A  i  to  2  per  cent,  solution  of  cocain,  containing  i  :  10,000 
adrenalin,  is  then  injected  into  the  anterior  and  posterior  pillars, 
carrying  some  of  the  solution  down  under  the  base  of  the  tonsil. 
When  carefully  injected  it  is  not  necessary  to  use  more  than  40  to 
60  minims,  which  should  result  in  a  perfect  anesthesia  in  a  few 


Figs.  251,  252. — Outline  of  points  of  injection  for  anesthesia  of  frontal  sinus;  i, 
Peuchart  point  of  injection  for  nasal  nerve ;  2,  point  of  injection  on  side  of  cheek 
for  reaching  sphenomaxillary  fossa.  (Braun.) 

minutes.  As  the  tonsil  is  being  separated  from  the  pillars  and  its 
bed,  if  any  pain  is  complained  of,  swabbing  over  the  area  will 
control  it. 

Hemorrhage  is  usually  very  slight,  owing  to  the  use  of  adrenalin, 
but  if  any  occurs  it  must  be  perfectly  controlled  before  leaving  the 
case,  as  it  may  increase  as  the  effects  of  the  adrenalin  pass  off. 

Larynx  and  Trachea. — Any  applications  to  the  larynx  is  best 
preceded  by  a  preliminary  spraying  with  a  2  to  5  per  cent,  solution, 
having  the  patient  inhale  at  the  time,  preferably  using  graduated 
bottles. 

The  superficial  anesthesia  secured  in  this  way  will  permit  of  the 
easy  use  of  the  swab  later,  which  is  used  with  a  20  per  cent,  solution. 

To  anesthetize  the  trachea  a  5  to  10  per  cent,  solution  is  usually 
necessary,  which  is  sprayed  in  at  the  moment  of  inspiration,  hav- 


644  LOCAL   ANESTHESIA 

ing  the  patient  expectorate  any  which  may  accumulate  in  the 
pharynx. 

In  all  operations  upon  the  above-mentioned  parts,  where  the 
procedure  is  at  all  protracted,  the  operator  is  warned  of  returning 
sensibility  by  the  return  of  vascularity  and  oozing  of  the  parts,  which 
always  precede  the  return  of  sensation  and  afford  time  for  the 
application  of  additional  anesthetic. 

In  very  extensive  operations  within  the  nasal  cavities  consider- 
able advantages  may  often  be  offered  by  blocking  the  superior 
maxillary  nerve  where  it  leaves  the  foramen  rotundum,  as  described 
in  the  chapter  on  the  Head.  This  could  be  supplemented  by  the 
use  of  adrenalin  locally  to  control  the  hemorrhage,  or,  under  extreme 
conditions,  ligating  the  external  carotid  artery. 

Under  certain  conditions  it  may  be  advisable  to  use  combined 
methods  of  anesthesia,  which  are  discussed  under  this  heading. 

For  operations  upon  the  frontal  sinus  the  field  is  embraced  in  an 
area  of  infiltration,  as  shown  in  Figs.  251,  252,  carrying  the  infil- 
tration deep  down  to  the  periosteum,  at  the  orbital  margin,  to  reach 
the  supra-orbital  and  supra trochlear  nerves  at  this  point;  following 
this  very  light  infiltration  is  necessary  laterally  and  above,  but 
may  often  be  found  unnecessary.  Anesthesia  of  the  mucous  lining 
of  the  sinus  is  controlled  by  a  median  orbital  injection  made  at  point 
i,  for  the  technic  of  which  see  chapter  on  the  Head. 

DENTAL  ANESTHESIA 

Here  all  methods  of  anesthesia  find  a  field  of  application,  from 
ethyl  chlorid  and  topical  applications  down  to  the  more  extensive 
operations  performed  under  regional  anesthesia.  Ethyl  chlorid  is 
used  in  the  opening  of  abscesses  and  other  simple  incisions,  and  is 
sometimes  employed  for  extractions.  For  this  purpose  the  ordinary 
container  may  be  used,  which  sprays  one  side  of  the  gum  at  a  time, 
or  a  specially  devised  instrument,  with  a  fork-shaped  or  two- 
pronged  tip,  which  directs  the  spray  to  both  sides  at  the  same  time. 

For  the  purposes  of  infiltration  about  four  agents  are  now  em- 
ployed— namely,  cocain,  /3-eucain,  alypin,  and  novocain — together 
with  a  large  number  of  proprietary  mixtures,  which  contain  mixtures 
of  the  above  agents  with  other  ingredients  in  different  proportions, 
most  of  them  containing  adrenalin. 

Thymol  is  one  of  those  agents,  and  seems  preferred  by  the  great 
majority  of  dentists,  as  this  agent  combines  antiseptic  and  anesthe- 
tic qualities;  in  dilutions  of  1:2000  it  prevents  the  development  of 


ORGANS   OF   SPECIAL   SENSE   WITH  DENTAL  ANESTHESIA 


bacteria,  and  in  more  concentrated  solution,  i  :2oo  it  is  destructive 
to  most  organisms.  Dentists  frequently  make  use  of  this  quality 
as  well  as  its  anesthetic  effect  by  applying  solutions  to  sensitive 
pulp  cavities;  this  anesthetic  property  is  quite  decided.  Experi- 
ments upon  animals  show  that  1:1000  solutions  will  paralyze  the 
cutaneous  nerve-endings  of  frogs  immersed  in  it  for  a  short  time. 


Fig.  253. — Injection  syringe  of  glass  and  metal,  designed  by  Dr.  Guido  Fischer.     (See 
Fig.  254  for  explanation  of  lettering.) 

As  reccomended  by  Fischer,  the  proportion  in  anesthetic  mixtures 
should  be  about  1:5000.  He  prefers  the  following  formula,  which 
he  recommends  for  infiltration  purposes: 

Novocain 1.5 

NaCl 0.92 

Thymol 0.025 

Distilled  water..  100.0 


646 


LOCAL   ANESTHESIA 


For  all  practical  purposes  our  solution  No.  2  (i  and  2  per  cent, 
novocain),  with  5  drops  of  adrenalin  to  the  ounce,  will  be  found 
amply  sufficient,  much  cheaper,  and  more  satisfactory  than  the 
many  proprietaries  now  on  the  market,  or  the  solution  recom- 
mended by  Fischer  may  be  used.  For  injection  into  the  gums 
specially  constructed  syringes  with  short,  stout  needles,  often  directed 


Fig.  254. — Needles,  awls,  and  wrench  for  injection  syringe,  designed  by  Dr.  Guido 
Fischer.  At  the  left  is  a  considerably  enlarged  reproduction  of  the  new  needle,  showing 
the  details  of  construction  as  follows:  i,  The  hollow  needle,  either  of  seamless  steel,  pure 
nickel,  gold,  or  iridio-platinum;  2,  body  of  soft  metal  for  firmly  tightening  the  needle 
upon  the  orifice  of  the  syringe;  3,  conical  shell  of  hard  metal,  open  below,  from  which  the 
soft  metal  cone  protrudes.  This  arrangement  remedies  the  deficiencies  of  the  old  styles 
of  needles  in  which  the  unprotected  soft  metal  cone  could  not  stand  much  use,  became 
flattened  easily,  and  jammed  in  the  hub  so  firmly  that  both  hub  and  needle  had  to  be 
replaced,  which  was  rather  expensive  if  gold  or  iridio-platinum  needles  were  used.  The 
new  needles  are  attached  to  the  syringe  absolutely  tightly  by  inserting  the  needle  in  one 
of  the  hubs  (b  or  c)  and  screwing  it  firmly  on  the  orifice  of  the  syringe.  In  oder  to  enable 
practitioners  with  sensitive  fingers  easily  to  manipulate  the  hubs,  which  heretofore  were 
milled,  the  hubs  b  and  c,  also  the  middle  pieces  d  and  e,  are  made  with  hexagonal  con- 
nections, so  that  they  can  be  conveniently  and  firmly  tightened  by  a  slight  turn  of  the 
wrench.  No  force  should  be  used,  otherwise  the  soft  metal  cone  of  the  needle  becomes 
unnecessarily  worn.  (Fischer.) 

at  an  angle,  are  necessary,  as  the  ordinary  syringe  and  needle  will 
not  stand  the  pressure  needed  to  infiltrate  such  dense  tissue.  The 
syringe  and  needles  shown  in  Figs.  253  and  254  have,  after  a  thorough 
experience,  been  found  to  fill  all  requirements,  and  have  been  adopted 
by  Fischer. 

The  dental  nerves  and  their  areas  of  distribution  are  seen  in 


ORGANS    OF    SPECIAL   SENSE    WITH   DENTAL   ANESTHESIA 


647 


Figs.  148,  165,  166,  167,  and  168,  and  a  more  thorough  description  is 
given  in  the  chapter  on  the  Head. 

It  should  be  remembered  that  dental  anesthesia,  when  applied 


a 

Fig.  255. — Position  of  needle  in  mucous  anesthesia,  aperture  of  needle  pointing 
toward  the  bone:  a,  Correct  position;  b,  incorrect  position.  The  point  of  the  needle  is 
forced  into  the  periosteum  and  to  the  bone.  (After  Seidel.) 

to  the  roots  of  the  teeth,  is  practically  always  a  paraneural  injection, 
and  may  require  ten  or  fifteen  minutes  to  become  effective.  These 
injections  should  be  made  subperiosteally  rather  than  under  the 


Fig.  256. — Position  of  needle  for  horizontal  injections  in  several  upper  teeth;  o,  Labial 
injection;  b,  buccal  injection.     (After  Fischer.) 

mucous  membrane,  and  under  considerable  pressure,  as  this  solu- 
tion must  force  its  way  through  bony  tissue  to  reach  the  nerve-fibers 
at  the  root  of  the  tooth. 

Before  making  the  injection  the  surface  is  cleansed  and  touched 


648 


b  b 

Fig.   257. — Position  of  needle  for  in-  Fig.  258. — Position  of  needle  for  mu- 

jection  in  upper  canine:  a,  Labial  injec-      cous  anesthesia   in   upper   first  bicuspid, 
tion;  b, palatal  injection.    (After  Fischer.)       Above  is  seen   the  infra-orbital  foramen: 

a,  Buccal  injection;  b,  palatal  injection. 


Fig.  259. — Injection  in  palatal  mucous  membrane  at  lateral  incisor  region.     Syringe  is 
held  like  penholder.     (After  Fischer.) 


ORGANS    OF    SPECIAL    SENSE    WITH   DENTAL   ANESTHESIA 


649 


with  iodin.  The  needle  should  be  entered  at  a  right  angle  to  the 
mucous  surface,  injecting  as  the  needle  is  advanced,  and  slowly 
pushed  through  to  the  periosteum,  which  is  penetrated,  and  the 
needle  advanced  a  short  distance  along  the  bone  and  well  up  toward 
the  root  of  the  tooth;  the  opening  in  the  needle  point  should  always 
be  directed  toward  the  bony  surface  (Figs.  255,  258),  the  remainder 
of  the  solution  now  slowly  injected,  the  needle  withdrawn,  and  the 
finger  pressed  upon  the  point  of  injection  for  a  few  seconds.  In 


Fig.  260. — Position  of  needle  for  injection  at  maxillary  tuberosity.     (After  Fischer.) 

those  parts  of  the  mouth  in  which  the  needle  cannot  be  advanced 
at  a  right  angle  it  must  be  done  obliquely,  but  should  be  made  as 
nearly  at  right  angles  as  possible. 

Repeated  punctures  by  the  needle  are  to  be  avoided  when  pos- 
sible, as  two  or  more  teeth  can  be  injected  by  using  a  long  needle 
and  advancing  it  in  such  a  position  that  the  area  of  injection  can 
be  made  to  embrace  several  teeth  (Fig.  256). 

For  injections  upon  the  palatine  surface  the  needle  is  made  to 
enter  more  nearly  in  the  axis  of  the  tooth  (Figs.  257,  259),  inserted 
back  from  the  gum  margin,  and  advanced  to  a  subperiosteal  posi- 
tion over  the  root  apex.  In  dealing  with  the  upper  molars,  instead 
of  making  the  injection  as  above,  an  injection  can  be  made  into  the 
posterior  dental  canals  (regional  anesthesia),  this  injection  sufficing 
for  all  three  molars,  as  follows: 

On  the  lateroposterior  surface  of  the   tuber  maxillare  of  the 


650  LOCAL  ANESTHESIA 

superior  maxilla  are  seen  a  varying  number  of  foramina,  the  open- 
ings of  the  posterior- superior  dental  canals  through  which  the 
sensory  nerve-filaments  pass  to  the  three  upper  molars;  before  enter- 
ing these  canals  the  nerves  run  downward  and  forward  for  a  short 
distance  in  the  submucous  tissue  in  close  proximity  to  the  parent 
trunk.  (See  Figs.  148-165.) 

To  inject  these  nerves  in  this  position  the  mouth  is  held  half- 
open,  the  cheek  drawn  outward  and  upward,  and  the  zygomatic 
process  reached  with  the  finger;  the  needle  is  entered  high  up  in  the 
mucous  membrane  about  over  the  second  molar,  with  its  point 
directed  upward,  backward,  and  inward,  the  syringe  being  held 
well  away  from  the  bone;  the  solution  is  injected  as  the  needle  is 
advanced,  with  the  point  hugging  as  closely  as  possible  the  convex 
surface  of  the  tuberosity  (Fig.  260)  until  its  posterior  surface  is 
reached.  From  ^  to  i  dram  of  a  i  to  2  per  cent,  solution  of  a 
novocain-adrenalin  solution  is  distributed  along  the  track  of  the 
needle.  Ten  or  fifteen  minutes  may  be  required  to  attain  the 
maximum  anesthetic  effect. 

The  lingual  portion  of  the  inferior  maxilla  is  injected  in  a  similar 
manner,  but  where  several  teeth  are  to  be  anesthetized  it  will  be 
found  best  to  block  the  inferior  dental  nerve  at  its  entrance  into  the 
dental  canal,  as  described  in  the  chapter  on  the  Head. 

When  this  form  of  anesthesia  is  resorted  to  an  additional  injec- 
tion will  be  necessary  for  the  molars  on  their  buccal  surface,  as  this 
tissue  is  supplied  by  the  buccinator  nerve.  (See  Fig.  167.) 

A  review  of  the  appended  table  (pp.  652-654),  taken  from 
Fischer,  will  be  found  useful,  as  indicating  the  points  and  methods 
of  injection  in  simple  and  complicated  cases  as  well  as  the  amount 
of  anesthetic  solution  to  be  used. 

Some  years  ago  a  pressure  method  of  anesthesia  for  the  painless 
extirpation  of  pulps  was  introduced.  The  exact  origin  of  this 
method  seems  hard  to  trace;  it  was,  however,  early  reported  on  by 
Dr.  Kells,  of  New  Orleans,  and  H.  H.  Hill,  of  St.  Louis  (1899).  For 
its  success  it  is  necessary  that  the  pulp  be  exposed,  the  essential 
feature  being  the  driving  of  the  anesthetic  under  pressure  into  the 
root  canal  of  the  tooth.  It  is  carried  out  as  follows :  A  small  piece 
of  cotton  (or  spunk,  as  originally  recommended)  is  moistened  with 
alcohol,  and  then  touched  with  the  local  anesthetic,  preferred  in 
powdered  form,  so  that  a  few  small  crystals  adhere  to  the  cotton;  this 
is  placed  in  contact  with  the  exposed  pulp;  the  rest  of  the  cavity  is 
then  filled  with  ordinary  red  rubber  (unvulcanized) ;  light  pressure 


ORGANS   OF   SPECIAL   SENSE    WITH   DENTAL  ANESTHESIA  651 

is  then  applied  with  a  ball  burnisher  as  large  as  can  be  fitted  to  the 
cavity;  as  the  pain  ceases  the  pressure  is  increased  until  considerable 
force  is  exerted,  which  is  continued  for  a  few  minutes;  this  has  the 
effect  of  driving  the  anesthetic  into  the  pulp  canal.  When  the 
exposure  of  the  pulp  is  minute  after  the  first  application,  the  opening 
is  enlarged  and  the  process  repeated.  When  this  has  been  properly 
carried  out  it  should  permit  the  painless  use  of  the  broach. 

It  is  said  that  when  arsenic  has  been  previously  used  the  resulting 
anesthesia  is  not  usually  as  pronounced. 

Cataphoresis  has  been  used  in  dental  surgery,  but  is  not  very 
popular  and  requires  much  time.  Other  electric  devices  have  been 
used,  but  do  not  properly  come  within  the  scope  of  this  book. 

For  regional  methods  of  anesthesia  applicable  to  more  extensive 
dental  operations  reference  should  be  had  to  the  chapter  on  the 
Head,  which  describes  the  technic  necessary  for  regional  anesthesia 
of  the  upper  and  lower  jaws,  the  illustrations  being  particularly 
useful. 

"Additional  explanation  of  tables:  The  period  of  waiting  in 
Cases  i  to  10  is  about  ten  minutes;  after  injection  in  the  inferior 
dental  foramen  as  in  Nos.  n  to  16,  twenty  minutes.  In  Nos.  13 
to  1 6  no  injection  lingually  is  required.  All  combinations  of  anes- 
thesia of  several  teeth  on  one  side  can  easily  be  calculated  by  apply- 
ing to  the  first  and  last  tooth  of  the  series  to  be  anesthetized  the 
technic  specially  indicated  for  the  same  in  the  tables. 

"If  for  example,  the  right  half  of  the  upper  jaw,  from  the  canine 
to  the  third  molar,  is  to  be  anesthetized,  an  injection  is  made  in  the 
canine  fossa  at  the  root  apex  of  the  canine;  the  needle  is  then  ad- 
vanced along  the  periosteum  to  the  root  apex  of  the  second  bicuspid, 
injecting  altogether  2  c.c.;  then  i  c.c.  is  injected  at  the  maxillary 
tuberosity,  about  10  drops  in  the  posterior  palatine  foramen,  and 
about  0.25  c.c.  palatally,  between  the  canine  and  first  bicuspid." 


The  aim  of  this  book  has  been  to  set  forth  methods  of  local  anes- 
thesia applicable  to  different  parts  of  the  body;  hoping  that  as  the 
technic  is  perfected  the  field  of  use  will  broaden  and  humanity  reap 
the  benefit. 

"For  I  doubt  not  through  the  ages, 
One  increasing  purpose  runs, 
And  the  thoughts  of  men  are  widened 
With  the  process  of  the  suns." 


652 


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optic  foramen  from  sunilar  point. 

encountered  by  needle  in  lateral  orbit 
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outer  edge  of  fis.  orbitalis  sup.  from  ou 
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INDEX 


ABDOMEN,  317 

nerve  supply,  345 

Abdominal  cavity,  operations  within,  349 
quinin  anesthesia  in,  117 

muscles,  reflex  rigidity  of,  325 

operations,  indications  and  contraindi- 
cations for  local  anesthesia,  351,  353 

organs,  sensibility,  317,  328 

packs,  pain  from,  336 

pain,  325-327 

wall,  anesthesia  of,  347 
Abscess  of  liver,  operation  for,  308,  354 
Absorption,  effects  of  acids  on,  48 
of  alkalies  on,  48 

laws  governing,  170 
Acetanilid  in  rectal  diseases,  420 
Acids,  effects  of,  on  absorption,  48 
Adhesions,  intestinal,  pain  from,  336 
Adrenalin,  137 

action  with  different  anesthetics,  151, 
152 

antagonism  of,  to  strychnin,  144 

calcareous  degeneration  of  vessels  from, 
146 

deterioration,  141 

glycosuria  from,  145 

hemostasis  after  use,  150 

in  arterial  anesthesia,  216 

in  cocain  poisoning,  131 

in  enlarged  spleen,  144 

in  eye  surgery,  629 

in  rectal  diseases,  145 

in  snake-bite,  144 

in  spinal  analgesia,  438 

in  testing  collateral  circulation,  216 

maximum  dose,  154 

physiologic  action,  142 

surgical  uses,  148 

tests  of,  141 

toxic  action,  145 
Age,  influence  on  toxicity,  129 
Air,  experiments  with,  as  local  anesthetic, 

66 
Akoin,  81 


Alcohol,  action  on  injected  nerves,  615 
as  local  analgesic,  63-68 
injections,  disturbances  following,  616 
of  internal  laryngeal  nerve,  288 
of  nerves,  570 
technic,  614 

mixtures  in  spinal  analgesia,  468 
observations  following  injection,  69 
sterilization  of  cocain  with,  173 
Alexander  route  to  third  division  of  fifth 

nerve,  572 

Alkalies,  effects  of,  on  absorption,  48 
Allen's  method  of  abdominal  anesthesia, 

347 

solutions  of  novocain,  165 
Alypin,  83 

in  spinal  analgesia,  437 

with  adrenalin,  153 
Analgesia,  29 
Andolin,  71 

Anemia,  anesthetic  effects  of,  58 
Anesthesia,  29 

arterial,  76 

combined  methods,  198 

dolorosa  of  Liebreich,  53,  65 

of  abdominal  wall,  347 
Anesthesin,  93 

following  cautery,  95 

in  hemorrhoids,  95,  420 

in  rectal  diseases,  419,  420 

in  urticaria,  95 
Anesthetic  agents,  comparative  action,  99 

effects  of  anemia,  58 
Anesthetics,  combinations  of,  164 

general,  contraindications  to,  202 

local,  antipyrin  as,  70 

contraindications  to,  202 
Ankle,  272 

Anoci-association,  204 
Anorectal  region,  41 1 
Antagonists  to  toxicity,  194 
Anterior  crural  nerve,  259 

palatine  nerve,  568 

tibial  nerve,  261 


663 


664 


INDEX 


Antidolorin,  60 

Antidotes  to  cocain  poisoning,  131 

Antipyrin,  394 

as  local  anesthetic,  70 

in  rectal  disease,  420 
Antrum  of  Highmore,  642 
Aponeuroses,  sensibility  of,  38 
Apothesine,  96 
Appendectomy,  349-353 
Appendix,  operations  on,  353 
Aquapuncture,  63,  64 
Arachnoid  membrane  of  spinal  cord,  436 
Arm,  anesthesia  of,  229 
Arterenol,  137 
Arterial  anesthesia,  76,  211 

occlusion  by  bands,  283 
Arteries,  sensibilities  of,  39,  337,  344 
Artery,  common  carotid,  ligation,  283 

of  sleep,  1 8 
Artificial  respiration  in  cocain  poisoning, 

135 

in  collapse  from  spinal  analgesia,  468 
Auditory  canal,  anesthesia  of,  632 
Auriculotemporal  nerve,  514 
Axilla,  paraneural  injections  within,  236 

BABCOCK'S  spinal  analgesia  solutions,  450 
Back,  302,  312 

nerves  of,  313 

Bands  for  arterial  occlusion,  283 
Bartholin's  glands,  removal  of,  427 
Beckwith  adrenalin  test,  141 
Beta-eucain,  77 

action  of  adrenalin  with,  151 

in  spinal  analgesia,  437 
Bite,  snake-,  treatment,  189 
Bladder,  anesthesia  of,  113,  116 

female,  426 

inspecting  interior  of,  401 

nerve  supply  of,  382 

sensibility  of,  341,  394,  402 
Blocking  intercostal  nerves,  305 

nerve-,  159,  203 

pudic  nerve,  382 
Blood-pressure,    effect    of    pain  on,  30, 

340 

Bones,  225 

sensibility  of,  38,  225,  379 

Brachial  plexus,  227 
anatomy,  232 

intraneural  injection  of,  236 
Kulenkampff's  injection  of,  233 
paraneural  injection  of,  231 


Brain,  operations  on,  521 

sensibility  of,  27,  520 
Braun's  eucain  solutions,  79,  165 

injection  of  frontal  and  lacrimal  nerve, 

549 
of  third  division  of  fifth  nerve,  607 

method  of  abdominal  anesthesia,  347 

novocain  solutions,  165 
Breasts,  operations  on,  305 
Bromids  as  local  anesthetics,  70 

in  rectal  surgery,  420 

preceding     operations     on     nose     and 

throat,  637 

Brucin  as  local  anesthetic,  70 
Bubo,  263 
Bunions,  274 
Burgi's  law,  194,  200 
Burns,  anesthesia  in,  94 

chloretone  in,  91 

CALCAREOUS  degenerations  from  adrena- 
lin, 146 

Calcium  chlorid  in  sacral  anesthesia,  489 
in  solutions,  169 

Cancerous  growths,  286 
ulcers,  420 

Carbolic  acid,  67,  419,  420 

Carbon  dioxid  snow  as  local  anesthetic,  63 

Carbonic  acid  gas,  19 
first  use,  1 8 

Carbuncles,  312 

Carotid  artery,  common,  ligation,  283 

internal,  ligation  of,  284 
canal,  575 

Cartilage,  sensibility  of,  38 

Caruncles,  427 

Castration,  391 

Cataphoresis,  first  use  of,  20 

Cataract,  operations  on,  627 

Cauda  equina,  436 

Caudal  anesthesia,  486 

Cautery,  anesthesin  following,  95 
use  of  sodium  bicarbonate  after,  420 

Cavernous  sinus,  596 

Cavum  Meckeli,  597,  598 

Cellular  tissue,  sensibility,  38 

Cerebrospinal  fluid,  movements  of,  439 

specific  gravity  of,  441 
pressure,  effects  of  spinal  analgesia  on, 

471 

Cervix  uteri,  operations  on,  424 
Cesarean  section,  430 
Chalazion,  626 


INDEX 


665 


Chancroids,  anesthesia  in,  94,  384,  393, 

493 

Chest  wall,  anesthesia  of,  306 
Chloral  as  local  anesthetic,  70 

in  rectal  surgery,  420 
Chloretone,  89 

in  burns,  91 
Chloroform,  393 

death  from,  155 

first  use,  25 

in  sepsis,  202 

local  use,  20,  68 
Cinnamylcocain,  136 
Circular  anesthesia,  186 
Circumcision,  384,  385 
Cisterna  pontis,  597 

terminalis,  436 
Coca  bush,  leaves,  use  by  natives,  22 

plant,  22 
Cocain,  72 

aluminum  citrate,  72 
sulphate,  72 

as  affected  by  adrenalin,  151 

borate,  72 

cantharidate,  72 

concentrated  solutions,  169 

death  from,  127 

disadvantages  of  continuous  use  in  eye, 
625 

early  history,  21 

general  anesthesia  from,  221 

hypodermic    injection,    for    control    of 
psychic  disturbances,  330,  331 

in  spinal  analgesia,  436 

injections  in  neuralgia,  537 

lactate,  72 

local  use,  20,  24 

mydriatic  action,  77,  628 

nitrate,  72 

origin,  20 

phenate,  67,  72 

in  rectal  surgery,  420 

phosphate,  72 

physiologic  action,  74,  130 

poisoning,  130 
adrenalin  in,  132 
antagonists  to,  193 
treatment,  131 

saccharate,  72 

salicylate,  72 

solutions,  sterilization  of,  173 

stearate,  72 

synergistic  agents,  194 


Cocain,  tests  for,  73 

toxic  dose,  127 

use  in  glaucoma,  626 
Codamin,  197 
Codein,  197 

in  rectal  diseases,  420 
Codrenin,  71 
Cold,  early  use  of,  19 

effect  on  pain  of  operations,  18,  19,  60, 
181 

use  of,  as  anesthetic,  60 
Colic,  intestinal,  Nothnagel's  hypothesis, 

322 

Collapse  in  spinal  analgesia,  468 
Collateral  circulation  tested  with  adrena- 
lin, 216 

Colostomy,  349,  353 
Colporrhaphy,  424 
Combined    methods   of   anesthesia,    198, 

205,  35i 

Comparative  action  of  anesthetics,  99 
Conjunctiva,  operations  on,  626 
Constriction,  early  use,  19 
Constrictor,  .Esmarch's,  19 

in    preventing    absorption,    127,    128, 

159 

surgical  use  of,  149,  186 
Contraindications  to  local  anesthesia,  202, 

350,  35i,  370 
Conus  terminalis,  435 
Cornea,  operations  on,  626 
Cortical  anesthesia,  199 
Craniotomy,  521 

Cremaster  muscle,  nerve  supply,  382 
Crocodile,    powdered    skin    of,    for   local 

anesthesia,  18 
Crural  nerve,  anterior,  259 
Cryptopin,  197 
Curettage,  425 

Cutaneous  nerve,  external,  of  lower  ex- 
tremity, 260 
of  upper  extremity,  238 
internal,  lesser,  238 

of  upper  extremity,  238 
middle,  260 

of  lower  extremity,  259 
Cyclitis,  628 

Cycloform  as  local  anesthetic,  70 
Cystoscopy,  493 
Cystotomy,      suprapubic,      in      female, 

428 

in  male,  397 
vaginal,  in  female,  426 


666 


INDEX 


DEATH  from  chloroform,  155 
from  cocain,  127 
from  ether,  155 

Deep  injections,  technic,  183,  228 
Dental  anesthesia,  644 
nerve,  inferior,  515 

injection  of,  557 

superior,  injection  of,  at  mental  fora- 
men, 527 

Descending  palatine  nerves,  514 
Diaphragm,  sensibility  of,  308 
Diffusion,  46 
Digital  nerves,  251,  253 
Dura  mater  of  spinal  cord,  435 

sensibility  of,  519 
Dural  sac,  436,  487 

EAR,  630 

Ecgonin,  127 

Eclampsia,  spinal  analgesia  in,  464 

Elbow-joint,  anesthesia  of,  229 

nerve-supply  of,  226 
Electric  anesthesia,  71 

current,  first  use,  20 

stimulation  of  nerves,  42 
Epidural  anesthesia,  486 

space,  movements  of  fluid  in,  498 
Epileptics,  dangers  of  local  anesthesia  in, 

202 

Epinephrin,  137 
Epirenin,  137 
Epispadias,  389 
Erythroxylin,  20,  73 
Esmarch  constrictor,  19 
Esophagus,  operations  on,  291 

sensibility  of,  39,  342 
Ether  as  antidote  in  spinal  anesthesia,  135 
to  cocain,  131 

as  vascular  stimulant  in  spinal  analge- 
sia, 468 

death  from,  155 

first  use,  as  general  anesthetic,  25 
as  spray,  60 

in  combined  anesthesia,  199 

sprays,  first  use,  19 
Ethmoidal  foramina,  539 
Ethyl  chlorid,  60 

in  anal  region,  419 
in  dental  surgery,  644 
Eucain,  77 

action  of  adrenalin  with,  151 

Braun's  solutions  of,  165 

lactate,  78 


Eudrenal,  137 
Eusemin,  71 
Eustachian  canal,  575 
Experiments  in  spinal  analgesia,  472 
Extremity,  lower,  257 
nerve  supply,  259 
Eye,  625 

anesthesia  of,  by  Lowenstein  method, 

630 

by  Siegrist  method,  630 
disturbances    following    alcohol    injec- 
tions, 617 

effects  of  spinal  analgesia  on,  481 
enucleation  of,  629 
removal  of  foreign  bodies  from,  629 
Eyelids,  operations  on,  626 

FACE,  528 

Fat,  sensibility  of,  38 

Faucial  tonsil,  642 

Feet,  soles,  anesthesia  of,  190 

Femoral  hernia,  372 

Femur,  nerve  supply,  226 

operations  on,  270 
Fibrin,  effects  of,  on  osmosis,  47 
Fibula,  nerve  supply  of,  226 
Fifth  nerve,  510 

cutaneous  distribution,  617 
deep  distribution,  620 
resection  of  peripheral  branches,  536 
Filum  terminalis,  435,  487 
Fingers,  245 

anesthesia  of,  251,  253,  255 
Fischer  dental  anesthetic  mixture,  645 
Fissure  in  ano,  413,  420 
Fistula  in  ano,  41 7 

vesicovaginal,  426 
Food,  before  operations,  201 
Foot,  272 
anesthesia  of,  277 
sole  of,  274,  275 
Foramen,  Civinini,  579 
civinum,  579 
lacerum  anterius,  540 

medium,  575 
mental,  injection  of,  527 
of  Magendie,  436 
ovale,  573,  576 

methods  of  injecting,  571,  607,  608 
Braun's,  607 
Harris's,  571 
Offerhaus',  571,  608 
Ostwalt's,  571 


INDEX 


667 


Foramen    ovale,    methods    of    injecting, 
Schlosser's,  571 

rotundum,  injection  of,  550,  602,  611 

spinosum,  575 
Forearm,  anesthesia  of,  229 
Fossa,  jugular,  575 

middle,  of  skull,  596 
Fractures,  local  anesthesia  in,  227 
Frontal  nerve,  511 

sinus,  644 

GALACTOCELE, 310 

Gall-bladder  disease,  pain  in,  326 

operations,  349,  354 

sensibility  of,  326,  344 
Gall  ducts,  sensibility  of,  326 
Ganglion,  Gasserian,  597,  598 
injection  of,  571 

technic,  612 
Gascopin,  197 

Gasserian  ganglion,  597,  598 
injection  of,  371 
technic,  612 
Gastric  mucosa,  sensibility,  342 

ulcer,  pain  in,  343 
Gastro-enterostomy,  352 
Gastro-intestinal  tract,  mucous  membrane 

of,  sensibility,  342 
Gastrostomy,  349-351 
Gastrotomy,  349~35i 
Gautier's  test  for  cocain,  73 
Gelatin,  effects  on  osmosis,  47 

in  paravertebral  anesthesia,  499 

in  sacral  anesthesia,  489 
General     anesthesia,     contraindications, 

202 
through    intravenous    injection,    of 

local  anesthetics,  221,  329 
Genitocrural  nerve,  361 
Genito-urinary  organs,  379 
Glands,  lymphatic,  removal,  285 

of  neck,  removal,  285 
Glaucoma,  danger  of  cocajn  in,  626 

operations  for,  628 

Glucose  solutions  in  spinal  analgesia,  475 
Glycosuria  from  adrenalin,  145 
Goitre,  291 

colloidal,  292 

exophthalmic,  295 
Great  sciatic  nerve,  260 

intraneural  injection,  268 
Gum  arabic  solutions  in  spinal  analgesia, 

475 


Gynecologic  operations,  external,  420 
spinal  analgesia  in,  464 
within  abdomen,  429 

HACKENBRUCH'S  method,  186,  188,  263 
Hand,  245 

anesthesia  of,  241,  246,  255 

palm  of,  anesthesia  of,  190 
Hard  palate,  anesthesia  of,  568 
Harris  route  to  Gasserian  ganglion,  571 

to  superior  maxillary  nerve,  603 
Head,  507 
Heart,  action  of  cocain  on,  76 

sensibility,  307 
Heat,  vibrations  causing,  42 
Hemolytic  action  of  solutions  in  spinal 

analgesia,  440 
Hemorrhage  after  use  of  adrenalin,  150 

control  of,  in  prostatectomy,  405 
Hemorrhoidal  nerve,  inferior,  379 
Hemorrhoids,  413 

anesthesin  in,  95 
Hemostasis,  190 

after  use  of  adrenalin,  150 
Hernia,  359 

femoral,  372 

inguinal,  360,  365 

postoperative,  376 

strangulated,  370 

umbilical,  374 
Herpes  facialis,  622 

zoster,  spinal  analgesia  in,  451 
Hip,  267 
Holocain,  81 
Homorenon,  137,  152 
Humerus,  nerve  supply  of,  226 
Hydrocele,  391 
Hydrocotarnin,  197 
Hyperosmotic  salt  solution,  47 
Hypertonic  salt  solution,  47 
Hypodermic    injection,    preliminary,    in 
local  anesthesia,  193. 

syringe,  discovery,  20 

history,  190 

Hyposmotic  salt  solution,  47 
Hypospadias,  389 
Hypotonic  salt  solution,  47 
Hysterectomy,  vaginal,  425 

ICE,  first  use  of,  19 
Ichthyol,  420 

Ileus,  effects  of  spinal  analgesia  on,  469 
pain  in,  322 


668 


INDEX 


Iliohypogastric  nerve,  361 
Ilioinguinal  nerve,  361 
Incontinence  of  urine,  487 
Indications  for  local  anesthesia,  210,  350 
Infiltrations,  deep,  technic,  180 
Infra-orbital  canal,  injection  of,  526 

foramina,  526 
Infratrochlear  nerve,  512 
Inguinal  adenectomy,  263 

hernia,  360,  365 

region,  263 

Intercostal  nerves,  302 
blocking,  305 

neuralgia,  novocain  injections  in,  537 
Intercostohumeral  nerve,  injection  of,  229 
Interosseous  nerve,  posterior,  240 
Intestinal  adhesions,  pain  from,  336 

colic,  pain  in,  322 
pain  in,  cause,  318 

mucosa,  sensibility  of,  342 

perforation,  pain  in,  321 
Intestines,  effect  of  cocain  on,  77 
of  spinal  analgesia  on,  469 

operations  on,  354 

sensibility  of,  318,  329,  334,  341,  344 
Intra-abdominal  adhesions,  sensibility  of, 

320 
Intra-arterial  anesthesia,  211 

injections,  comparative  toxicity  of,  128, 

183,    222 

Intracranial  operations,  521 
Intraneural  injections,  183 

technic,  183 
Intravenous  anesthesia,  217 

injections,  comparative  toxicity  of,  1 28, 

183,    222 

salt  solution  as  antidote  in  cocain  poi- 
soning, 133 

Intravcsical  anesthesia,  401 
Iritis,  628 

Isatropyl  cocain,  136 
Ischiorectal  abscess,  418 
Isosmotic  salt  solution,  47 
Isotonic  salt  solution,  47 

JOINTS,  225,  226 
Jonnesco's  spiral  analgesia,  484 
Jugular  fossa,  575 
vein,  internal,  283 

KELENE,  60 

Kidney,  effect  of  cocain  on,  77 
of  spinal  analgesia  on,  476 


Kidney,  operations  on,  407,  502 

Kiliani   route  to  third  division   of   fifth 

nerve,  572 

Killian  regional  anesthesia  of  nasal  cav- 
ity, 640 

Knee,  amputation  at,  267 
Knee-joint,  nerve  supply  of,  226 

operations  on,  270,  271 
Kulenkampff  injection,  complications  fol- 
lowing, 236 
of  brachial  plexus,  233 

LABOR,  sacral  anesthesia  in,  492 

spinal  anesthesia  in,  464,  470 
Lacrimal  nerve,  511 
Lanthopin,  197 
Laryngeal  nerve,  external,  283 
inferior,  283 
internal,  alcohol  injection  of,  288 

blocking,  282 
Laryngectomy,  289 
Larynx,  287,  643 

innervation,  282 
Laudanidin,  197 
Laudanin,  197 
Laudanocin,  197 
Leg,  272 

Levy  and  Baudoin,  injection  of,  543 
Liebreich's  anesthesia  dolorosa,  53,  65 
Ligamentum  denticulatum,  436 
Ligation  of  common  carotid  artery,  283 

of  internal  carotid  artery,  284 

of  subclavian  artery,  284 

of  thyroid  vessels,  296 
Light  vibrations,  42 
Lingual  nerve,  515,  569 

tonsil,  642 

Lip,  lower,  operations  on,  529 
Lipectomy,  355 
Liver  abscess,  operation  for,  308,  354 

sensibility  of,  318,  326 
Llipta,  24 

Local  anesthesia,  advantages,  360,  361, 374 
contraindications,  202 
general  anesthesia  from,  221,  329 
in  combination  with  quinin  salts,  120 
Lowenstein  method  in  anesthesia  of  eye, 

630 

Lower  extremity,  257 
nerve  supply,  259 

lip,  operations  on,  529 
Lung,  sensibility  of,  307 
Lymphatic  glands,  removal,  285 


INDEX 


669 


MACLAGAN'S  test  for  cocain,  73 
Magendie,  foramen  of,  436 
Magnesium  salts,  123 

in  spinal  analgesia,  476 
in  tetanus,  124 
Malignant  growths,  286 
Mammary  glands,  operations  on,  310 
Mandragora  atropa,  18 
Marrow,  sensibility  of,  38 
Mastoid  antrum,  operations  on,  632 
Matas  infiltrator,  175,  184 

route  to  superior  maxillary  nerve,  550 
Maxilla  inferior,  resection  of,  531 
Maxillary  artery,  internal,  601 

nerve,  inferior,  514 
Meatus,  urethral,  anesthesia  of,  387 
Median  nerve,  238 

injection  of,  238,  241,  246,  248 
Meningeal    symptoms    following    spinal 

analgesia,  471 

Mental  foramen,  injection  of,  527 
Mesentery,  sensibility  of,  317,  322,  341, 

344 

Metatarsals,  274 
Methoxycaffein,  68 
Methyl  chlorid,  61 

iodid,  60 

oxid,  60 
Methylil,  61 
Miconidin,  197 
Middle  cutaneous  nerve,  260 
Mikulicz  pack  in  prostatectomy,  405 
Military  surgery,  spinal  analgesia  in,  465 
Morphin  and  scopolamin  in  spinal  anal- 
gesia, 454 
preliminary  use,  192 

as  antidote  in  cocain  poisoning,  133 

as  local  anesthetic,  70 

in  anesthetic  solutions,  164 

local  use,  20 

Mucous  membranes,  sensibility  of,  38,  342 
Muscle  sensibility,  38 
Musculocutaneous  nerve  of  lower  extrem- 
ity, 263 

of  upper  extremity,  238 
Musculospiral  nerve,  239 

NARCEIN,  197 

Narcophen,  196 

Narcotin,  197 

Nasal  cavity,  regional  anesthesia  of,  639 

Nasofrontal  duct,  642 

Nasopharynx,  642 


Neck,  279 

nerves  of,  279 

operations  on,  283 
Needles,  173 

for  making  spinal  puncture,  458 
Nerves,  occipital,  blocking,  515 

alcohol  injections  of,  570 

anterior  crural,  259 
palatine,  568 

blocking,  568 
tibial,  261 

auriculo  temporal,  514 

blocking,  159,  203,  269 

descending  palatine,  514 

digital,  251 

dorsal,  of  penis,  379 

external  cutaneous,  of  lower  extremity, 

259 
of  upper  extremity,  238 

laryngeal,  283 

plantar,  261 

popliteal  or  peroneal  nerve,  261 
fifth,  510 
frontal,  511 

blocking,  515,  549 
functions,  27 

electricity  and,  42 

vibratory  theory,  41,  42 
genitocrural,  363 
great  sciatic,  260 
iliohypogastric,  361 
ilioinguinal,  361 
inferior  dental,  515 
blocking,  557 

hemorrhoidal,  379 

maxillary  514 

or  recurrent  laryngeal,  283 

pudendal,  381 

blocking,  383 
infraorbital,  blocking,  526 
infratrochlear,  512 
intercostal,  blocking,  305 
internal  cutaneous,  of  lower  extremity, 

260 
of  upper  extremity,  238 

laryngeal,  282 
blocking,  282 

or  long  saphenous,  260 

plantar,  261 
lacrimal,  511 

lesser  internal  cutaneous,  238 
lingual,  515,  569 

blocking,  569 


6yo 


INDEX 


Nerves,  median,  238 
middle  cutaneous,  260 
musculocutaneous,  of  lower  extremity, 
263 

of  upper  extremity,  238 
musculospiral,  239 
nasal,  512 

blocking,  549 
nasopalatine,  514,  568 

blocking,  568 
obturator,  259 
occipitalis  major,  517 

minor,  517 
of  ankle-joint,  226 
of  back,  313 
of  elbow-joint,  226 
of  femur,  226 
of  fibula,  226 
of  humerus,  226 
of  knee-joint,  226 
of  lower  extremity,  259 
of  neck,  279,  281 

blocking,  281,  285 
of  radius,  226 
of  thorax,  302 

intercostal,  302 

posterior  or  long  thoracic,  305 

supra-acromial,  304 

supraclavicular,  304 

twelfth  dorsal,  302,  304 
of  tibia,  226 
of  ulna,  226 

of  upper  extremity,  226 
of  wrist-joint,  226 
ophthalmic,  510 
palmar,  251 
perineal,  379,  381 
posterior  interosseous,  240 

superior  dental,  blocking,  649 

tibial,  261 

injection,  275 
pudic,  379 

blocking,  382 
radial,  240 

result  of  injury  to,  360 
sensations  of,  26 
small  sciatic,  260 
sphenopalatine,  513 
superior  dental,  514 

laryngeal,  282 

maxillary,  512 

blocking,  550,  603 
supraorbital,  512 


Nerves,  supraorbital,  blocking,  515 

supra trochlear,  512 

tempo romalar,  512 

ulnar,  239 

Nervous  system,  effects  of  spinal  anal- 
gesia on,  477 
Neumann  method  for  mastoid  anesthesia, 

632 
Neuralgia,  cocain  injections  in,  537 

novocain  injections  in,  537 
Nose,  634 

external,  operations  on,  637 

operations  on,  by  combined  methods, 

200 
Nothnagel's  hypothesis  of  intestinal  colic, 

322 
Nourishment  after  operation,  201 

before  operation,  201 
Novocain,  85 

action  of  adrenalin  with,  151,  153 

Allen's  solutions  of,  165 

Braun  solutions  of,  165 

in  spinal  analgesia,  437 

injections  in  neuralgia,  537 

maximum  dose  used,  129 

nitrate,  88 

sloughing  following  use,  622 

OBERST   method  of   regional  anesthesia, 

252,  384 
Obstetrics,  sacral  anesthesia  in,  492 

spinal  analgesia  in,  464,  470 
Obturator  nerve,  259 
Occipitalis  major  nerve,  517 

minor  nerve,  517 
Occlusion  of  arteries,  283 
Ocular  disturbances  following  alcohol  in- 
jections of  ganglion,  617 
palsies      following     spinal     analgesia, 

481 
Offerhaus   route   to   foramen  ovale,  571, 

608 

to  foramen  rotundum,  611 
Oily  solutions,  172 

in  spinal  analgesia,  475 
Omentum,  sensibility  of,  39 
Ophthalmic  nerve,.  510 
Opiates,  192 
Opium  and  alkaloids  as  antidotes,  133 

local  use  of,  20 
Orbits,  539 
Orchidectomy,  391 
Organs  of  special  sense,  625 


INDEX 


671 


Orthoform,  92,  420 

Osmosis,  46 

Osteomas,  removal  of,  270 

Osteotomy,  270 

Ostwalt  route  to  foramen  ovale,  571 

Ovarian  cysts,  429 

Oxynarcodin,  197 

PACINIAN  bodies,  27,  38 

Packs,  abdominal,  pain  from,  336 

Pain,  26 

abdominal,  325-327 

definition,  29 

effect  on  blood-pressure,  30,  340 

from  abdominal  packs,  336 

from  intestinal  adhesions,  336 

in  ileus,  322 

in  intestinal  perforation,  321 

in  peritonitis,  321 

in  volvulus,  322 

philosophy,  44 

pressure  theory,  43 

psychic  control,  34,  35,  193 

rate  of  transmission,  33 

special  nerves  for,  33 

theories,  39 

Painful  impressions,  lasting  qualities,  33 
Palm  of  hand,  anesthesia  of,  190 
Palmar  nerves,  251,  253 
Pantopon,  196 

as  antidote  in  cocam  poisoning,  133 
Papaverin,  197 
Paracentesis,  632 
Paraneural  injections,  182 
Paraphimosis,  384 
Parasacral  anesthesia,  502 
Paravertebral  anesthesia,  494 

of  cervical  region,  499 
Patella,  fracture,  operation  on,  270,  271 
Patrick  route  to   third  division  of  fifth 

nerve,  572 
Pelvic  neuroses,  487 
Peuchart  injection,  548 
Penis,  dorsal  nerve,  379 

operations  on,  383,  493 
Pericardium,  sensibility,  307 
Perichondrium,  sensibility,  38 
Perineal  nerves,  379,  381 
Perineorrhaphy,  423,  493 
Perinephritic  abscess,  411 
Perineum,  operations  on,  422 
Periosteum,  sensibility,  38 
Perirectal  abscess,  418 


Peritoneum,  parietal,  sensibility  of,  317, 

319,  324,  336 

visceral,  317 
Peritonitis,  pain  in,  321 
Peroneal  nerve,  261 
Phenol,  67 

Philosophy  of  pain,  44 
Phimosis,  384 

Phrenic  nerve,  sensibility,  318 
Pia  membrane  of  spinal  cord,  436 
Plantar  nerve,  external,  261 

internal,  261 
Pleasure-pain  sense,  29 
Pleura,  sensibility,  307 
Pneumogastric  nerve,  sensibility,  317 
Poisoned  wounds,  189 
Poisoning,  cocain,  adrenalin  in,  132 

treatment,  131 

Popliteal  nerve,  external,  261 
Porus  trigeminus,  597 
Posterior  interosseous  nerve,  240 

or  long  thoracic  nerve,  305 

superior  dental  nerves,  anesthesia  of, 
649 

tibial  nerve,  261 

injection,  275 
Postoperative  hernia,  376 

nourishment,  201 

Potassium   sulphate   in   anesthetic    solu- 
tions, 169 
Preparatory  hypodermic  injections,  193 

treatment,  361,  364 
Pressure  anesthesia  in  dental  surgery,  650 

anesthetic  effects,  58 

first  use  of,  17,  19 

theory  of  pain,  43 
Principles  of  technic,  155 
Proposin,  96 
Prostatectomy,  395,  493,  506 

control  of  hemorrhage  in,  405 
Prostatic  abscess,  407 
Protopin,  197 
Psychic  control  of  sensations,  36 

by  injection  of  cocain,  330,  331 
Pterygium,  629 
Pudendal  nerve,  blocking,  382 

inferior,  381 
Pudic  nerve,  379. 
blocking,  382 

QUINCKE'S  point  for  spinal  puncture,  456 
Quinin    and  urea    in    sacral    anesthesia, 
490 


672 


INDEX 


Quinin  in  intra-abdominal  surgery,  117 
in  rectal  surgery,  115,  420 
salts,  109,  206 
tetanus  from,  120 

RABID  animals,  bites  of,  189 
Radial  nerve,  240 

injection  of,  240,  241,  246,  247 
Radius,  nerve  supply  of,  226 
Rami  communicantes,  345,  494 
Rectal  diseases,  adrenalin  in,  145 

mucosa,  sensibility  of,  342 

neuralgia,  420 

operations,  anesthesia  in,  95,  115,  413 

prolapse,  413 

surgery,  carbolic  acid  in,  419 
sodium  bicarbonate  in,  420 

ulcers,  417 

Rectum,  operations  on,  413,  417,  493,  506 
Recurrent  laryngeal  nerve,  283 
Reflex  rigidity  of  abdominal  muscles,  325 
Regional  anesthesia,  159,  182 

by  Schleich  infiltration,  185,  244 
Respiration,  artificial,  in  cocain  poisoning, 

135 

in  collapse  from  spinal  analgesia,  469 
in  poisoning,  135 
effects  of  spinal  analgesia  on,  468 
Ribs,  resection  of,  306 
Round  ligaments,  external  operations  on, 

428 
internal  operations  on,  430 

SACRAL  anesthesia,  486 
gelatin  in,  489 
in  labor,  492 
quinin  and  urea  in,  489 
sodium  bicarbonate  in,  489 

sulphate  in,  489 
hiatus  and  canal,  488 
Saline  infusion  for  collapse  in  spinal  anal- 
gesia, 468 

Salpingo-oophorectomy,  429 
Salt  solution,  intravenous,  in  cocain  poi- 
soning, 133 

normal,  as  antidote  in  cocain  poison- 
ing, 133 

Saphenous  nerve,  long,  260 
Scalp  tumors,  520 

wounds,  520 
Scarpa's  triangle,  263 
Schleich's  regional  anesthesia,  185,  244, 
253 


Schleich's  solutions,  164,  165 
Schlosser  alcohol  injections,  570 

route  to  foramen  ovale,  571 

rotundum,  603 
Schultz  adenotome,  642 
Sciatic  nerve,  great,  260 

intraneural  injection,  268 
intraneural  injection  of,  273 
method  of  locating,  268 
Sciatica,  novocain  injections  in,  537 

spinal  analgesia  in,  451 
Scopolamin,  action  of,  196 

and  morphin  in  spinal  analgesia,  454 

preliminary  use  of,  192 
Scrotum,  nerve  supply  of,  382 

operations  on,  389 
Sebaceous  cysts,  520 
Sensation,  distribution  of,  37 
Sensibility  of  aponeurosis,  38 

of  arteries,  39,  337,  344 
Sensory  nerve  endings,  26 
Sequestrotomy,  270 
Shock,  195, 199,  202,  204 

from  local  anesthesia,  203 

spinal  anesthesia  in,  203 
Siegrist  method  in  eye  anesthesia,  630 
Skin  grafting,  259,  264 

method  of  anesthetizing,  176 
Skull,  middle  fossa  of,  596 
Sleep,  artery  of,  18 
Small  sciatic  nerve,  260 
Snake-bite,  antagonism  of  adrenalin  to, 
144 

treatment,  189 
Snow,  first  use  of,  19 
Sodium  bicarbonate,  after  cautery,  420 
in  sacral  anesthesia,  489 

carbonate  in  solutions,  168 

phosphate  in  solutions,  168 

sulphate  in  sacral  anesthesia,  489 
Solutions,  Allen's,  166 

Braun's,  165 

concentrated,  action,  169 

for  spinal  analgesia,  437 

in  oil,  172 

uses,  158 

Sound  vibrations,  42 
Spermatic  cord,  nerve  supply  of,  382 
Sphenoidal  fissure,  540 
Sphenomaxillary  fissure,  540 
Sphenopalatine  nerve,  513 
Sphygmogenin,  138 
Spinal  analgesia,  432 


INDEX 


673 


Spinal  analgesia,  adrenalin  in,  438 
after  effects,  470 

treatment,  485 

changes  in  spinal  cord  after,  478 
collapse  in,  468,  470,  472 

artificial  respiration  in,  469 

saline  infusion  in,  468 
contraindications,  450,  471 
effects    of    intraspinal    pressure    in, 
462 

on  abdominal  organs,  469 

on  eyes,  481 

on  intestines,  469 

on  nervous  system,  477 

on  pressure  of  cerebrospinal  fluid, 

47i 

on  respiration,  468 

on  stomach,  469 

on  sympathetic  nerves,  469 

on  temperature,  470 

on  uterus,  470 

on  vascular  system,  467 
experimental  work  in,  472,  479 
failures  in,  462,  463 
for  uterine  hemorrhage,  464 
gangrene  from,  478 
glucose  solution  in,  475 
gum  arabic  in,  475 
hemolytic  action  of  solutions  in,  440 
in  eclampsia,  464 
in  gynecology,  464 
in  herpes  zoster,  451 
in  labor,  464 
in  military  surgery,  465 
in  obstetrics,  464 
in  sciatica,  451 

incontinence  of  urine  after,  478 
indications,  450 
intradural  hemorrhage  in,  471 
Jonnesco  method,  484 
magnesium  salts  in,  475 

salts  in,  in  tetanus,  475 
meningeal  symptoms  following,  471 
needle  for,  458 
oily  solutions  in,  475 
phenomena  of,  466 
physiologic  action,  466 
position  of  patient  in,  456 
preparation  of  patient,  462 
puncture  points  in,  455 
solutions  for,  437,  450 
technic,  453-462 
vertigo  in,  471 

43 


Spinal  anesthesia,  ether  in  collapse  from, 

135 
in  shock,  203 

canal,  curves  of,  444 

movements  of  anesthetic  solutions  in, 
445 

cord,  anatomy  of,  435 

changes  in,  after  spinal  analgesia,  478 
Spleen,  enlargement  of,  adrenalin  in,  144 
Sprays,  use  of,  in  nose  and  throat,  637 
Sterilization  of  cocain  solutions,  173 
Sternum,  312 

Stomach,  effects  of  spinal  analgesia  on, 
469 

operations  on,  349,  351 

sensibility  of,  319,  344 
Stone  of  Memphis,  18 
Stovain,  83 

hemolytic  action,  in  spinal  analgesia,  440 

in  spinal  analgesia,  437 
Strangulated  hernia,  370 
Strictures,  urethral,  anesthesia  of,  387 
Strychnin,  antagonism  of  adrenalin  to,  144 

as  antidote,  in  cocain  poisoning,  133 

in  spinal  analgesia,  455,  484 
Subarachnoid  space,  436 
Subclavian  artery,  284 
Subcutaneous  injections,  comparative  tox- 

icity,  128,  222 
Subcutin,  95 

Sub  maxillary  glands,  removal  of,  529 
Submental  glands,  removal  of,  529 
Subtemporal  decompression,  524 
Superior  dental  nerve,  514 

laryngeal  nerve,  282 

maxillary  nerve,  512 

blocking  of,  Harris  method,  603 
Supra-acromial  nerves,  304 
Supraclavicular  nerves,  304 
Supraorbital  foramina,  526 

nerve,  512 

Suprarenin,  137,  152 
Supratrochlear  nerve,  512 
Swabs,  u'se  of,  in  nose,  638 
Sympathetic  nerves,  345 

effects  of  spinal  analgesia  on,  469 
sensibility  of,  317 

Synergists  to  local  anesthetics,  194,  200 
Synovial  membranes,  sensibility  of,  225 
Synthetic  adrenalin,  137,  151 
Syphilitic  ulcers,  420 
Syringes,  173 

for  spinal  analgesia,  458 


674 


INDEX 


TABLETS,  anesthetic,  176 
Tactility,  rate  of  transmission,  33 
Taste,  sense  of,  effects  of  ganglion  injec- 
tions on,  621 

Technic,  principles  of,  155 
Temporal  fossa  of  skull,  596 
Temporomalar  nerve,  512 
Tendo  achillis,  tenotomy  of,  278 
Tendon  sheaths,  sensibility  of,  38 
Tendons,  sensibility,  38 
Testicle,  nerve  supply,  382 
Tetanus  from  quinin  injections,  1 20 

magnesium  salts  in,  124,  475 
Thebein,  197 
Thermo-anesthesia,  29 
Thigh,  267 

amputation,  258,  267 
Thoracic  wall,  anesthesia  of,  306 
Thoracotomy,  308 
Thorax,  302 

nerves  of,  302 
Throat,  634 

operations  on,  by  combined  methods, 

200 

Thymol  in  dental  anesthetics,  644 
Thyroid  vessels,  ligation  of,  296 
Tibia,  nerve  supply  of,  226 
Tibial  nerve,  anterior,  261 
Tiefenthal  method  for  paracentesis,  632 
Toe  nails,  removal,  275 
Toes,  274 
Tongue,  anesthesia  of,  569 

removal  of,  537 
Tonogen,  632 

Tonsillar  tumors,  removal  of,  538 
Tonsils,  642 

Toxic  symptoms,  anatagonists  to,  194 
Trachea,  287,  643 
Trachelorrhaphy,  425 
Tracheotomy,  287 
Transthoracic  hepatotomy,  308 
Tritopin,  197 
Tropacocain,  82 

action  of  adrenalin  with,  151 

in  spinal  analgesia,  437,  450 
Tuberculous  glands  of  neck,  285 

ulcers,  420 

Turner's  point  for  spinal  analgesia,  456 
Turbinate  bones,  anesthesia  of,  640 
Twilight  sleep,  195 
Tympanum,  anesthesia  of,  632 


ULNA,  nerve  supply  of,  226 
Ulnar  nerve,  239 

injection  of,  239,  241,  247,  248 
Umbilical  hernia,  374 
Upper  extremity,  224 

nerves  of,  238 

Urethra,  male,  anesthesia  of,  386,  387,  493 
Urethral  stricture,  adrenalin  in,  144 
Urethrotomy,  384,  387 

external,  384,  387 

internal,  384 
Urinary  changes  after  spinal  analgesia, 

476 

Urine,  incontinence  of,  486 
Urticaria,  anesthesia  in,  95 
Uterine  fibroids,  430 

hemorrhage  after  labor,  spinal  analgesia 
in,  464,  470 

polypi,  427 

suspension,  430 
Uterus,  action  of  adrenalin  on,  143 

effects  of  spinal  analgesia  on,  470 

sensibility,  344 
Uvula,  642 

VAGINAL  hysterectomy,  425 
outlet,  anesthesia  of,  423 
wall,  operations  on,  422 

Varicocele,  391 

Varicose  veins  of  leg,  265 

Vascular  system,  effects  of  spinal  anal- 
gesia on,  467 

Vein,  internal  jugular,  284 

Veins,  sensibility,  39,  337,  344 

Vertigo  in  spinal  analgesia,  471 

Vesicovaginal  fistula,  426 

Vibratory  theory  of  nerve  function,  41 

Visceral  perforation,  pain  in,  321 

Volvulus,  pain  in,  322 

Von  Eicken  method  for  anesthetizing  ex- 
ternal auditory  canal,  632 

WATER  anesthesia,  63,  159 
in  rectal  surgery,  418 
Welt  anesthesia,  54 
Wheal,  production  of,  176 
Wounds,  closure  of,  190 

technic  of  handling,  187 
Wrist,  nerve  supply  of,  226 

XANTHALIN,  197 


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Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches ;  with  over  100  new  and  elaborate  tables  and  many  hand- 
some illustrations.  By  W.  A.  NEWMAN  BORLAND,  M.  D.  Large 
octavo,  1 1 37  pages,  bound  in  full  flexible  leather,  $4. 50  net ;  with  thumb 
index,  $5.00  net.  Published  August,  191  s 

The  American  Illustrated  Medical  Dictionary  defines  hundreds  of  terms  not 
denned  in  any  other  dictionary — bar  none.  It  gives  the  capitalization  and  pro- 
nunciation of  all  words.  It  makes  a  feature  of  the  derivation  or  etymology  of  the 
words.  Every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a 
word  quickly.  The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the 
greatest  help  in  assembling  anatomic  facts.  Every  word  is  given  its  definition — a 
definition  that  defines  in  the  fewest  possible  words. 

Howard  A.  Kelly,  M.  D.,  Johns  Hopkins  University,  Baltimore. 

"  The  American  Illustrated  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such 
convenient  size.  No  errors  have  been  found  in  my  use  of  it." 

Owen's  Treatment  of  Emergencies 

The  Treatment  of  Emergencies.  By  HUBLEY  R.  OWEN,  M.  D., 
Surgeon  to  the  Philadelphia  General  Hospital.  I2mo  of  350  pages, 
with  249  illustrations.  Cloth,  $2. oo  net.  Published  June,  1917 

Dr.  Owen's  book  is  a  complete  treatment  of  emergencies.  It  gives  you  not 
only  the  actual  technic  of  the  procedures,  but,  what  is  equally  important,  the  un- 
derlying principles  of  the  treatments,  and  the  reason  why  a  particular  method  is 
advised.  You  get  treatments  of  fractures,  of  contusions,  of  wounds.  Particularly 
strong  is  the  chapter  on  gun-shot  wounds,  which  gives  the  new  treatments  that  the 
great  European  War  has  developed.  You  get  the  principles  of  hemorrhage,  to- 
gether with  its  constitutional  and  local  treatments.  You  get  chapters  on  sprains, 
strains,  dislocations,  burns,  sunburn,  chilblain,  asphyxiation,  convulsions,  hysteria, 
apoplexy,  exhaustion,  opium  poisoning,  uremia,  electric  shock,  bandages,  and 
a  complete  discussion  of  artificial  respiration,  including  mechanical  devices. 


DISEASES   OF   CHILDREX. 


Kerley's  Pediatrics 

Practice  of  Pediatrics.  By  CHARLES  GILMORE  KERLEY,  M.  D., 
Professor  of  Diseases  of  Children,  New  York  Polyclinic  Medical  School 
and  Hospital.  Octavo  of  878  pages,  illustrated.  Cloth,  $6.00  net; 

Half   MorOCCO,   $7.5O  net.  Published  March,  1914 

FOURTH  LARGE  PRINTING 

This  work  is  not  a  cut-and-dried  treatise — but  the  practice  of  pediatrics,  giving 
fullest  attention  to  diagnosis  and  treatment.  The  chapters  on  the  newborn  and  its 
diseases,  the  feeding  and  growth  of  the  baby,  the  care  of  the  mother's  breasts, 
artificial  feeding,  milk  modification  and  sterilization,  diet  for  older  children — from 
a  monograph  of  125  pages.  Then  are  discussed  in  detail  every  disease  of  child- 
hood, telling  just  what  measures  should  be  instituted,  what  drugs  given,  60  valu- 
able prescriptions  being  included.  The  chapter  on  -vaccine,  therapy  is  right  down  to 
the  minute,  including  every  new  method  of  proved  value — with  the  exact  technic. 
There  is  an  excellent  chapter  on  Gymnastic  Therapeutics.  Another  feature  con- 
sists of  the  165  illustrative  cases — case  teaching  of  the  most  practical  sort. 

Dr.  A.  D.  Blackader,  Me  Gill  University,  Montreal 

"  Dr.  Kerley  is  a  pediatrician  of  large  experience  who  thinks  for  himself  and  is  never  con- 
tent to  accept,  without  testing,  the  experiences  or  statements  of  previous  writers.  His  book  has 
a  verv  definite  value." 


Handler's  The  Expectant  Mother 

Published  August,  1916 

This  is  decidedly  a  book  for  the  woman  preparing  for  childbirth.  It  has 
chapters  on  menstruation,  nourishment  of  mother  during  pregnancy,  nausea, 
care  of  breasts,  examination  of  urine,  preparations  for  labor,  care  of  mother  and 
child  after  delivery,  twilight  sleep,  and  dozens  of  other  matters  of  great  interest 
to  the  expectant  mother. 

i2mo  of  213  pases,  illustrated.  By  S.  WYLLIS  HANDLER,  M.  D.,  Professor  of  Diseases  of  Women.  New 
York  Post-Graduate  Medical  School  and  Hospital.  Cloth,  $1.25  net. 

Winslow's  Prevention  of  Disease 

Published  November,  1916 

This  book  is  a  practical  guide  for  the  layman,  giving  him  briefly  the  means 
to  avoid  the  various  diseases  described.  The  chapters  on  diet,  exercise,  tea. 
coffee,  and  alcohol  are  of  special  interest,  as  is  that  on  the  prevention  of  cancer. 
There  are  chapters  on  the  prevention  of  malaria,  colds,  constipation,  obesity, 
nervous  disorders,  tuberculosis,  etc.  The  work  is  a  record  of  twenty-rive 
years'  active  practice. 

i2mo  of  348  pages,  illustrated.  By  KENELM  WINSLOW,  M.  D.,  formerly  Assistant  Professor  of  Com- 
parative Therapeutics,  Harvard  University.  Cloth.  $1.75  net. 

Kerr's  Diagnostics  of  Children's  Diseases 

Dr.  Kerr's  work  is  written  absolutely  for  the  general  practitioner — to  aid  him 
in  diagnosing  disease  in  his  child  patients.  He  approaches  his  subject  as  'the 
child  is  approached  in  the  sick-room.  It  is  strictly  a  clinical  work — a  first  aid 
in  the  diagnosis  of  disease  in  children.  Published  February,  1907 

Octavo  of  542  pages,  illustrated.  By  LE  GRAND  KERR.  M.  D.,  Professor  of  Diseases  of  Children  in  the 
Brooklyn  Postgraduate  Medical  School.  Brooklyn.  Cloth.  $5.00  net;  Half  Morocco,  $6.50  net. 


SAUNDERS'  BOOKS    ON 


Hill  and  Gerstley's  Infant  Feeding'          Ready  soon 

CLINICAL  LECTURES  IN  INFANT  FEEDING/  By  LEWIS  WEBB  HILL, 
M.  D.,  Alumni  Assistant  in  Pediatrics,  Harvard  Medical  School,  and 
JESSE  R.  GERSTLEY,  M.  D.,  Clinical  Assistant  in  Pediatrics,  North- 
western University  Medical  School,  ismo  of  300  pages,  illustrated. 

In  these  clinics  you  are  given  the  full  details  of  the  Boston  method  of  infant 
feeding  as  developed  by  Dr.  Rotch,  and  of  the  Chicago  method.  You  are  given  the 
theory,  use  in  both  normal  and  abnormal  cases,  exact  quantities  and  percentages, 
and  concrete  clinical  examples.  The  book  is  equivalent  to  a  postgraduate  course 
in  infant  feeding.  It  brings  these  two  systems  right  to  your  door. 

Abt's  Preparation  of  Infants'  Foods 

THE  PREPARATION  or  INFANTS'  FOODS.  By  ISAAC  A.  ABT,  M.D., 
Professor  of  Diseases  of  Children,  Northwestern  University  Medical 
School.  i2mo  of  143  pages.  Cloth,  $1.25  net.  Published  juiy,  1917 

This  is  a  practical  guide  for  infant  feeding,  giving  to  young  mothers,  nurses,  and 
caretakers  minute  directions  on  the  preparation  of  food  for  infants  and  young 
children.  You  get  weights  and  measures;  the  mineral  constituents  and  caloric 
values  of  foods.  'You  get  such  practical  material  as  diet-lists  for  constipation  in 
older  children,  an  outline  of  a  plan  for  feeding  babies,  care  of  nipples  and  bottles, 
etc.,  and  a  great  host  of  recipes  for  beverages  of  all  kinds,  milk  preparations,  soups 
and  broths,  puddings  and  cereal  preparations,  custards,  eggs,  vegetables,  fruits, 
meats,  sea  foods,  and  breads. 


Aikens'  Home  Nurse's  Hand-Book 

HOME  NURSE'S  HAND-BOOK.  By  CHARLOTTE  A.  AIKENS.  i2mo  of 
303  pages,  illustrated.  Cloth,  $1.50  net. 

The  point  about  this  work  is  this:  It  tells  you  and  shows  you  just  how  to  do  those 
little  but  important  things  often  omitted  from  other  nursing  books.  "Home  Treat- 
ments" and  "Points  to  be  Remembered"  —  terse,  crisp  reminders  —  stand  out  as  par- 
ticularly practical.  Just  the  book  for  those  who  have  the  home-care  of  the  sick. 


Galbraith's  Personal  Hygiene  for  Women 

PERSONAL  HYGIENE  AND  PHYSICAL  TRAINING  FOR  WOMEN.  By 
ANNA  M.  GALBRAITH,  M.  D.  i2mo  of  393  pages,  with  original  illus- 

trations.     Cloth,  $2.25  net.  Published  January,  191  7 

"  It  contains  just  the  sort  of  information  which  is  very  greatly  needed  by  the  weaker 
sex.  Its  illustrations  are  excellent."  —  Dietetic  and  Hygienic  Gazette. 

Galbraith's  Four  Epochs  of  Woman's  Life  Ne£dit?odn 

THE  FOUR  EPOCHS  OF  WOMAN'S  LIFE.  By  ANNA  M.  GALBRAITH, 
M.  D.  With  an  Introductory  Note  by  JOHN  H.  MUSSER,  M.  D.,  Uni- 
versity of  Pennsylvania.  1  2mo  of  296  pages.  Cloth,  $1.50  net. 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public  ; 
but  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  h,  in  the  main,  wise  and  whole- 
some."— Birmingham  Medical  Review.  Published  March,  1917 


CHILDREN  AND   HYGIENE 


Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  CROZER  GRIFFITH,  M.  D.,  Professor 
of  Pediatrics  in  the  University  of  Pennsylvania.  I2mo  of  455  pages, 
illustrated.  Cloth,  $1.50  net. 

SIXTH  EDITION— published  June,  1915 

The  author  has  endeavored  to  furnish  a  reliable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  so  that  the  volume  will  be  of 
service  to  mothers  and  nurses. 

New  York  Medical  Journal 

"We  are  confident  if  this  Itttle  work  could  find  its  n&f  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  would  be  lessened  by  at  least  fifty  per  cent." 


Infant  Feeding.  By  CLIFFORD  G.  GRULEE,  M.  D.,  Assistant  Pro- 
fessor of  Pediatrics  at  Rush  Medical  College.  Octavo  of  3 16  pages,  illus- 
trated, including  8  in  colors.  Cloth,  $3.00  net. 

SECOND  EDITION— published  April,  1914 

Dr.  Grulee  tells  you  how  to  feed  the  infant.  He  tells  you — and  shows  by  clear 
illustrations — the  technic  of  giving  the  child  the  breast.  Then  artificial  feeding  is 
thoughtfully  presented,  including  a  number  of  simple  formulas.  The  colored  illus- 
trations showing  the  actual  shapes  and  appearances  of  stools  are  extremely 
valuable, 

Ruhrah's   Diseases   of    Children 

A  Manual  of  Diseases  of  Children.  By  JOHN  RUHRAH,  M.  D., 
Professor  of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 

Baltimore.     I2mo  of  552  pages,    fully    illustrated.     Flexible   leather, 
$2.75  net. 

FOURTH  EDITION— published  September,   1914 

In  revising  this  work  for  the  fourth  edition  Dr.  Ruhrah  has  carefully  in- 
corporated all  the  latest  knowledge  on  the  subject.  All  the  important  facts  are 
given  concisely  and  explicitly,  the  therapeutics  of  infancy  and  childhood  being 
outlined  very  carefully  and  clearly.  There  are  also  directions  for  dosage  and 
prescribing,  and  many  useful  prescriptions  are  included. 

American  journal  of  the  Medical   Sciences 

"Treatment  has  been  satisfactorily  covered,  being  quite  in  accord  with  the  best  teaching, 
yet  withal  broadly  general  and  free  from  stock  prescriptions." 


SAUNDERS\    BOOKS    ON 


Reefer's  Military  Hygiene 

Military  Hygiene  and  Sanitation.  By  LiEux.-CoL.  FRANK  R, 
KEEPER,  Professor  of  Military  Hygiene,  United  States  Military  Academy, 
West  Point.  I2mo  of  305  pages,  illustrated.  Cloth,  $1.50  net. 

Published  July,   1914 

This  is  a  concise,  though  complete  text-book  on  this  subject,  containing 
chapters  on  the  care  of  troops,  recruits  and  recruiting,  personal  hygiene,  physical 
training,  preventable  diseases,  clothing,  equipment,  water-supply,  foods  and  their 
preparation,  hygiene  and  sanitation  of  posts  and  barracks,  the  troopship,  hygiene 
and  sanitation  of  marches,  camps,  and  battlefields,  disposal  of  wastes,  tropical  and 
arctic  service,  venereal  diseases,  alcohol  and  other  narcotics,  and  a  glossary. 


Bergey's  Hygiene 

The  Principles  of  Hygiene  :  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  BERGEY,  A.  M.,  M.  D., 
Assistant  Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  531  pages,  illustrated.  Cloth,  $3.00  net. 

FIFTH  EDITION—  published  September,   1914 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practises  are  based,  and  to  aid  physicians  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  years. 
This  fifth  edition  has  been  very  carefully  revised,  and  much  new  matter 
added,  so  as  to  include  the  most  recent  advancements. 

Buffalo  Medical  Journal 

"  It  will  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  water 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 

Pyle's  Personal  Hygiene  New  (TM  Edition-August,  1917 


A  MANUAL  OF  PERSONAL  HYGIENE  :  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  WALTER  L.  PYLE,  A.  M., 
M.  D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  555  pages,  fully  illustrated.  Cloth,  $1.50  net. 

The  book  has  been  thoroughly  revised  for  this  new  edition,  and  a  new  chapter  on 
Food  Adulteration  by  DR.  HARVEY  W.  WILEY  added.  There  are  important  chapters 
on  Domestic  Hygiene  and  Home  Gymnastics,  Hydrotherapy,  Mechanotherapv  and 
First  Aid  Measures. 

"  The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers 
have  succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound 
knowledge."—  Boston  Medical  and  Surgical  Journal. 


LEGAL   MEDICINE 


Bohm  and  Painter's  Massage 

Massage.  By  MAX  BOHM,  M.  D.,  of  Berlin,  Germany.  Edited,  with  an 
Introduction,  by  CHARLES  F.  PAINTER,  M,  D.,  Professor  of  Orthopedic  Sur- 
gery at  Tufts  College  Medical  School,  Boston.  Octavo  of  91  pages,  with  97 

practical  illustrations.        Published  June,  191  3  Cloth,  $1.75  net. 

Golebiewski  and  Bailey's  Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.      By   DR.   ED. 

GOLEBIEWSKI,  of  Berlin.  Edited,  with  additions,  by  PEARCE  BAILEY,  M.  D., 
Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York.  With  71  colored 
illustrations  on  40  plates,  143  text  illustrations,  and  549  pages  of  text.  Cloth, 
$4.00  net.  In  Saunders  Hand-Atlas  Series.  Published  1001 

Hofmann   and   Peterson's   Legal   Medicine 


Atlas  of  Legal  Medicine.  By  DR.  E.  VON  HOFMANX,  of  Vienna. 
Edited  by  FREDERICK  PETERSON,  M.  D.,  Professor  of  Psychiatry  in  the 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
and  193  half-tone  illustrations.  Cloth,  $3.50  net.  Published  April,  1898 

Jakob  and  Fisher's  Nervous  System  saunden* 

Atlases 
Atlas  and   Epitome  of  the  Nervous   System  and   its  Diseases.      By 

PROFESSOR  DR.  CHR.  JAKOB,  of  Erlangen.  Edited,  with  additions,  by  ED- 
WARD D.  FISHER,  M.  D.,  University  and  Bellevue  Hospital  Medical  College. 
With  83  plates  and  copious  text.  Cloth,  $3.50  net.  Published  1001 

Spear's  Nervous  Diseases  Published  November,  ms 

A  Manual  of  Nervous  Diseases.  By  IRVING  J.  SPEAR,  M.D,.  Professor 
of  Neurology  at  the  University  of  Maryland,  Baltimore.  I2mo  of  660  pages- 
illustrated.  Cloth,  $2.75  net. 

This  is  a  comprehensive  digest,  supplying  the  means  to  a  clear  understanding  of 
neurology,  and  robbing  that  subject  of  much  of  its  difficulty.  You  are  given,  first, 
a  brief  description  of  the  practical  anatomy  and  physiology,  with  those  facts  and 
theories  that  bear  on  the  mechanism  of  organic  nervous  diseases.  Then  pathology- 
is  given,  the  simpler  diseases  being  considered  first,  gradually  preparing  the  reader 
to  grasp  the  more  difficult  ones.  The  descriptions  are  clear  and  -brief,  differential 
diagnoses  and  treatments  being  brought  out  very  definitely.  Only  the  most  recent 
accepted  facts  have  been  considered.  For  the  treatments  recommended,  no  special 
apparatus  is  required  beyond  a  galvanic  and  faradic  battery;  they  demand  no 
special  training,  and  they  are  easily  remembered. 


io  SAUNDERS'  BOOKS  ON  CHILDREN. 

American  Pocket  Dictionary  New  (9th)  Edition 

AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited  by  W.  A.  NEW- 
MAN BORLAND,  M.  D.,  Editor  "American  Illustrated  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  75  extensive  tables. 
With  693  pages.  Flexible  leather,  with  gold  edges,  $1.25  net;  with 
patent  thumb  index,  $1.50  net.  Published  April,  1915 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  Dear, 
of  the  Jefferson  Medical  College,  Philadelphia. 

Morrow's  Immediate  Care  of  Injured  second  Edition 

IMMEDIATE  CARE  OF  THE  INJURED.  By  ALBERT  S.  MORROW,  M.  D., 
Adjunct  Professor  of  Surgery  at  the  New  York  Polyclinic.  Octavo  of  360 
pages,  with  242  illustrations.  Cloth,  $2.50  net.  Published  March,  1912 

Dr.  Morrow's  book  on  emergency  procedures  is  written  in  a  definite  and  decisive  style, 
the  reader  being  told  just  what  to  do  in  every  emergency.  It  is  a  practical  book  for  every 
day  use,  and  the  large  number  of  excellent  illustrations  can  not  but  make  the  treatment  to 
be  pursued  in  any  case  clear  and  intelligible.  Physicians  and  nurses  will  find  it  indispensible. 

Powell's  Diseases  of  Children  Third  Edition,  Revised 

ESSENTIALS  OF  THE  DISEASES  OF  CHILDREN.  By  WILLIAM  M.  POWELL, 
M.  D.  Revised  by  ALFRED  HAND,  JR.,  A.  B.,  M.  D.,  Dispensary 
Physician  and  Pathologist  to  the  Children's  Hospital,  Philadelphia. 
i2mo  volume  of  259  pages.  Cloth,  $1.25  net.  In  Saunders* 
Question-  Compend  Series.  Published  March,  1001 

Shaw  on  Nervous  Diseases  and  Insanity        Fifth  Edition 

ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY  :  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  the  late 
JOHN  C.  SHAW,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  $1.25  net.  In  Saunders'  Question- Com- 
pend Series.  Published  October,  1913 

"  Clearly  and  intelligently  written ;  we  have  noted  few  inaccuracies  and  several  sug- 
gestive points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted.' 
— Boston  Medical  and  Surgical  Journal. 

Brady's  Personal  Health  published  September,  me 

PERSONAL  HEALTH:  A  Doctor  Book  for  Discriminating  People.  By 
WILLIAM  BRADY,  M.D.,  Elmira,  N.  Y.  i2mo  of  406 pages.  Cloth,  $i.5onet 

Hecker,  Trumpp,  and  Abt  on  Children 

ATLAS  AND  EPITOME  OF  DISEASES  OF  CHILDREN.  By  DR.  R.  HECKER 
and  DR.  J.  TRUMPP,  of  Munich.  Edited,  with  additions,  by  ISAAC  A. 
ABT,  M.D.,  Assistant  Professor  of  Diseases  of  Children,  Rush  Medical 
College,  Chicago.  With  48  colored  plates,  144  text-cuts,  and  453  pages 

Of  text.       Cloth,  $5-00  net.  Published  April,  J907 

The  many  excellent  lithographic  plates  represent  cases  seen  in  the  authors'  clinics,  and 
have  been  selected  with  great  care,  keeping  constantly  in  mind  the  practical  needs  of  the 
general  practitioner.  These  beautiful  pictures  are  so  true  to  nature  that  their  study  is 
equivalent  to  actual  clinical  observation.  The  editor,  Dr.  Isaac  A.  Abt,  has  added  all  new 
methods  of  treatment. 


University  of  California 

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405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

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